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PRINCIPLES OF SURGERY 



N. SENN, M.D., Ph.D., LL.D. 

Professor of Surgery in Rush Medical College in Affiliation with the University of Chicago ; Professorial 
Lecturer on Military Surgery in the University of Chicago ; Attending Surgeon to the Presbyterian 
Hospital : Surgeon-in-Chief to St. Joseph's Hospital ; Surgeon-General of Illinois ; Late 
Lieutenant-Colonel of United States Volunteers and Chief of the Operating- 
staff with the Army in the Field during the Spanish-American "War. 



THIRD EDITION. THOROUGHLY REVISED 



UJitb 230 mood-engravings, fialf-tones, and Colored illustrations 




■ _ 



PHILADELPHIA AND CHICAGO 

F. A. DAVIS COMPANY, PUBLISHERS 

1901 






I\ \ 



THE LIBRARY OF 

CONGRESS, 
Two Copies Received 

APR. 26 1901 

Copyright entry 
CLASS CL XXc. N«. 

& ! C O 

COPY B, 



COPYRIGHT, 1890, 

BY 

F. A. DAVIS. 
COPYRIGHT, 1895, 

BY 

THE F. A. DAVIS COMPANY. 
COPYRIGHT, 1901, 

BY 

F. A. DAVIS COMPANY. 

[Registered at Stationers' Hall, London, Eng.] 



"l « 
I I t 



Philadelphia, Pa., U. S. A.: 

The Medical Bulletin Printing-house, 

1916 Cherry Street. 



PREFACE TO FIEST EDITION. 



A modern work on the principles of surgery in the English lan- 
guage has become a generally and well-recognized necessity. The recent 
great discoveries relating to the etiology and pathology of surgical dis- 
eases have made the text -books of only a few years ago old and almost 
worthless. The many treatises on surgery, by American and English 
authors, which have made their appearance in rapid succession during 
the last ten years or more, are replete with valuable practical informa- 
tion, but most of them are defective in those parts relating to the 
matter treating of the fundamental principles of the art and science 
of surgery. 

It has been my aim to write a book for the student and general 
practitioner which should, at least in part, fill this gap in surgical litera- 
ture, and which should serve the purpose of a systematic treatise on the 
causation, pathology, diagnosis, prognosis, and treatment of the injuries 
and affections which the surgeon is most frequently called upon to treat. 
The successful study and practice of any branch of the healing art re- 
quire a thorough knowledge of the principles upon which it is based. 
The student who has mastered the principles of surgery will have no 
difficulty in applying his knowledge in practice, while the one who has 
burdened his memory with numerous details to meet special indications 
is always at a loss in making prompt and judicious use of his thera- 
peutic resources when confronted by rare lesions or unexpected emer- 
gencies. 

In writing this book it has been my intention to keep in constant 
view the difference between the cellular processes, as we observe them 
in regeneration and inflammation, and to connect the modern science 
of bacteriology more intimately with the etiology and pathology of sur- 
gical affections than has heretofore been done by most authors who have 
written on the same subjects. In showing the direct etiological rela- 
tionship which exists between certain pathogenic microorganisms and 
definite pathological processes, I have frequently made liberal use of 
the experimental and clinical material contained in my work on "Sur- 
gical Bacteriology." When the subject of tumors was reached it was 
found that the manuscript had become so voluminous that it was deemed 
advisable to publish the volume without this part of the intended scope 
of the work, — an arrangement to which the publisher kindly gave his 
consent. It is the author's intention to make good this defect by the 

(iii) 



IV PEEFACE. 

preperation, in the near future, of a special work on "The Pathology 
and Surgical Treatment of Tumors." 

With few exceptions the sources from which my information was 
taken are not given, as a copious bibliography would have required 
considerable valuable space. At the same time the author hopes that 
he has presented the views and opinions of the authorities quoted with 
sufficient clearness and thoroughness to render a resort to the original 
articles, in most instances, unnecessary. Among the text-books which 
I have consulted I desire to mention the following: Histology: Klein, 
Schafer, Heitzmann, and Satterthwaite. Pathology: Klebs, Hamilton, 
Birch-Hirschfeld, Paget, Yirchow, Coates, Lebert, Eindfleisch, Belafield, 
and Prudden. The Principles of Surgery: Konig, Hueter-Lossen, Lan- 
derer, Billroth- Winiwarter, and Van Buren. Bacteriology: Fltigge, 
Baumgarten, and Cruikshank. The illustrations were selected from 
modern text-books not readily accessible to the average student. 

A prolonged absence from home made it impossible for the author 
to attend the proof-reading, and he asks the indulgence of the reader 
for any imperfections which may appear in the book from any sources 
for which he cannot be held personally responsible. 

Should this volume become the means of lightening and facilitating 
the student's work in acquiring a thorough knowledge of the funda- 
mental principles of surgery, and of serving as a useful source of in- 
formation for the busy general practitioner, the author will feel abun- 
dantly rewarded for the many sleepless nights which were required in 
its preparation. 

K Senx. 
Milwaukee, October, 1890. 



PEEFACE TO THIED EDITION. 



The text of this edition has been thoroughly revised and many 
additions made, among them two new chapters, one on "Degeneration" 
and the other on "Blastomycetic Dermatitis": subjects which should 
be included in a text-book on the "Principles of Surgery." Many new 
illustrations have been added, most of them original. The author be- 
speaks for this the same favorable consideration as has been so freely 
showered upon the first two editions. 



K Senn. 



Chicago. 1901. 



(j) 



TABLE OF CONTENTS. 

PAGE 

Preface to First Edition iii 

Preface to Third Edition v 

Table of Contents vii 

List of Illustrations xi 

CHAPTER I. 
Regeneration 1 

CHAPTER II. 
Regeneration of Different Tissues 31 

CHAPTER III. 
Degeneration 81 

CHAPTER IV. 
Inflammation 91 

CHAPTER V. 
Inflammation {continued) 120 

CHAPTER VI. 
Pathogenic Bacteria 157 

CHAPTER VII. 
Necrosis ' 187 

CHAPTER VIII. 
Necrosis (continued) 205 

CHAPTER IX. 

Suppuration 220 

(vii) 



Y111 TABLE OF CONTENTS. 

CHAPTER X. 
Suppuration (continued) 244 

CHAPTER XI. 
Ulceration and Fistula 269 

CHAPTER XII. 
Suppurative Osteomyelitis 274 

CHAPTER XIII. 

Suppuration in Large Cavities; Abscess of Internal Organs. . 309 

CHAPTER XIY. 
Septicemia 354 

CHAPTER XV. 
Pyemia 383 

CHAPTER XVI. 
Erysipelas 411 

CHAPTER XVII. 
Tetanus 436 

CHAPTER XVIII. 
Hydrophobia 459 

CHAPTER XIX. 
Surgical Tuberculosis 475 

CHAPTER XX. 
Clinical Forms of Surgical Tuberculosis 506 

CHAPTER XXL 
Tuberculosis of Lymphatic Glands and Peritoneum 529 

CHAPTER XXII. 
Tuberculosis of Bones and Joints 550 

CHAPTER XXIII. 
Tuberculosis of Tendon-sheaths, etc 591 



TABLE OF CONTENTS. IX 

CHAPTEE XXIV. 
Actinomycosis Hominis 619 

CHAPTEE XXV. 
Blastomtcetic Dermatitis 645 

CHAPTEE XXVI. 
Anthrax 659 

CHAPTEE XXVII. 
Glanders 679 

Index 693 



LIST OF ILLUSTRATIONS. 



FIG. PAGE 

1. A wound twenty-six hours old. (Thiersch) 4 

2. A wound twenty-six hours old. (Thiersch) 5 

3. Quiescent nucleus. (Flemming) 8 

4. Living cell of salamander. (Flemming) 8 

5. Endothelial cells. (Flemming) 9 

6. Epithelial cell of salamander. (Flemming) 10 

7. Epithelial cell of salamander. (Flemming) 10 

8. Epithelial cell of salamander. (Flemming) 11 

9. Cell-division. (McKendrick) 13 

10. Granulating wound. (Billroth- Winiwarter) 14 

11. Granulation-tissue from wound. (Hamilton) 15 

12. Superficial capillaries of a wound beginning to granulate. (Hamilton) 17 

13. Formation of new blood-vessels by budding. (Arnold) ' 18 

14. Development of blood-corpuscles in connective-tissue cells, and transformation of the 

latter into capillary blood-vessels. (Fliigge) 19 

15. Granulating wound undergoing cicatrization. (Landerer) 20 

16. Embryonal connective-tissue cell undergoing transformation into mature state. 

(Ziegler) 21 

17. Wandering epithelial cells from frog. (Klebs) 22 

18. Corneal corpuscles in a state of proliferation. (Senftleben) 33 

19. Wounds of cornea. (Von Wyss) 34 

20. Healing of experimental fracture of the tibia of a rabbit. (Colored) 35 

21. Rhinoplasty and transplantation of large skin-grafts. (Thiersch) 40 

22. Microscopical appearances of the interior of artery of dog 43 

23. Microscopical appearances of the interior of vein of dog 44 

24. Femoral artery of dog fifty days after double ligation with silk. (Natural size) 45 

25. Collateral circulation eight months after ligation of the aorta in a dog. (Luigi Porta) ... 46 

26. Muscular fibres near a wound in a state of proliferation. (O. Weber) 49 

27. Muscle-suture 50 

28. Tenorrhaphy. (Esmarch) 51 

29. Tendoplasty. (Esmarch) 51 

30. Secondary suturing of extensor tendons of fingers by the suture a distance 52 

31. Tendon elongations 53 

32. Section through callus. (Bajardi) 55 

33. Transverse section through callus. (Maas) 56 

34. Osteoclasts absorbing bone 58 

35. Old method of bone-suture 60 

36. Improved bone-suture 60 

37. Wire drawn through the perforation 60 

38. Wire cut in the centre and each half twisted separately 60 

39. Senn's hollow intraosseous splint 61 

40. Circular bone ferrule for humerus or femur made of an ox-femur 61 

41. Triangular bone ferrule for tibia made of an ox-tibia 61 

42. Wide perforated bone ferrule 61 

43. Oblique fracture of femur united by bone ferrule 62 

44. Transverse fracture of humerus immobilized by a wide perforated bone ferrule 62 

45. Senn's splint apparatus applied 63 

46. Senn's splint apparatus for treating fracture of the neck of femur 64 

47. Wound of kidney. (Tillmanns) 66 

48. Healing of wound of liver. (Tillmanns) 67 

49. Tubular suture of Van Lair with decalcified-bone tube 71 

50. Nerve-fibre in a state of regeneration. (Gluck) 72 

51. Longitudinal section through nerve. (Gluck) 73 

52. Nerve-suture, showing application of direct and paraneural sutures 75 

53. Neuroplasty. (Letievant) 78 

54. Cross-sutures. (Tillmanns) 78 

55. Ischaemic paralysis of muscles of leg 82 



(xi) 



Xll LIST OF ILLUSTRATIONS. 

FIG. PAGE 

56. Fatty degeneration of the heart-muscle 84 

57. Amyloid degeneration of the kidney. (Colored) 89 

58. Capillary vessels of the frog's mesentery. (Klein) 93 

59. Leucocyte, showing reticulum of protoplasmic strings. (Klein) 94 

60. Change of forms of a moving leucocyte by amoeboid movements. (Klein) 95 

61. Amoeboid movements of red blood-corpuscles. (Leonard) 97 

62. Third corpuscle. (Eberth and Schimmelbusch) 98 

63. Normal circulation in frog's web. (Landerer) 104 

64. Capillaries of frog's web in a state of hyperaemia soon after application of irritant. 

(Landerer) 105 

65. Plasma-cells in acute interstitial nephritis. (Low power. Colored) 106 

66. Three plasma-cells in acute interstitial nephritis. (High power. Colored) 108 

67. Leucocyte passing through capillary wall. (Landerer) 113 

68. Inflammation of frog's web at stage where capillary stream is imbedded by commencing 

emigration. (Landerer) 115 

69. Germinating endothelium. (Hamilton) 124 

70. Omentum of young dog, experimentally inflamed. (Hamilton) 125 

71. Acute pleurisy. (Hamilton) 126 

72. Artificial keratitis. (Hamilton) 133 

73. Phagocytosis. Struggle between anthrax bacillus and leucocyte 136 

74. Hueter's infusor 147 

75. Cold coil. (Esmarch) 151 

76. Cold coil for the head. (Leiter) 152 

77. Different forms of bacteria. (Baumgarten) 158 

78. Zooglcea 159 

79. Endogenous spore-production in bacillus anthracis cultivated upon meat-infusion pep- 

tone-gelatin. (Baumgarten) 160 

80. Spore of bacillus of anthrax. (De Bary) 161 

81. Gelatin cultures following surface inoculation. (Fliigge) 163 

82. Cultures in gelatin growing in the track made by the needle. (Fliigge) 164 

83. Experimentally-produced growth of streptococci in centre of cornea of rabbit. (Baum- 

garten) 191 

84. Dry gangrene of foot. (Lebert. Colored) 209 

85. Vertical section through a subcutaneous abscess. (Baumgarten. Colored) 225 

86. Microscopical pictures of staphylococcus. (Rosenbach) 231 

87. Common forms of pus-microbes. (Colored) 233 

88. Micrococcus pyogenes tenuis. (Rosenbach) 234 

89. Microscopical picture of streptococcus pyogenes. (Rosenbach) 234 

90. Bacillus pyogenes fcetidus. (Fliigge) 235 

91. Bacillus pyocyaneus. (Fliigge) 235 

92. Bacillus pyocyaneus 236 

93. Gonococcus. (Bumm) 236 

94. Gonorrhceal pus 237 

95. Gonorrhoeal conjunctivitis. (Bumm. Colored) 238 

96. Bacillus coli communis 238 

97. White corpuscles and pus-corpuscles. (Koch) 239 

98. Fragmentation of nucleus in leucocytes undergoing transformation into pus-corpuscles. 

(Landerer) 241 

99. Pus with staphylococcus. (Fliigge) 242 

100. Pus with streptococcus. (Fliigge) 242 

101. Pus-corpuscles. (Billroth -Winiwarter) 242 

102. Infiltration of connective tissue of cutis, with beginning suppuration in the centre. 

(Billroth- Winiwarter) 249 

103. "Vessels (artificially injected) from walls of an abscess artificially produced in the tongue 

of a dog. (Billroth-Winiwarter) 250 

104. Irrigating apparatus 258 

105. Osteomyelitis of the tibia 282 

106. Osteomyelitis of the tibia 284 

107. Osteomyelitis of the radius. (Sciagraph) 286 

108. Necrosis of humerus. (Lebert) 288 

109. Sequestra following acute diffuse suppurative osteomyelitis 289 

110. Hollow, padded, posterior splint. (Esmarch) 290 



LIST OF ILLUSTRATIONS. Xlll 

FIG. PAGE 

111. Board splint for upper extremity. (Esmarch) 290 

112. Wire splint. (Esmarch) 291 

113. Interrupted plaster-of-Paris splint 292 

114. Incision for necrotomy of the tibia 299 

115. Bone-cavity after removal of sequestrum and granulations in necrosis of the tibia. 

(Esmarch) 301 

116. Inversion of soft tissues on each side into the bone-cavity. (Neuber) 302 

117. Healing of bone-cavity. (Neuber) 302 

118. Osteoplastic necrotomy. (Bier) 304 

119. Shulten's method of necrotomy 305 

120. Central syphilitic osteomyelitis of the femur. (Sciagraph) 306 

121. Cortical syphilitic osteomyelitis of the femur. (Billings. Sciagraph) 306 

122. Gumma 307 

123. Bacillus typhosus. (Colored) 310 

124. Micrococcus gonorrhoeae. (Colored) 311 

125. Gonococcus. (Bumm) 312 

126. Motor areas 326 

127. Wilson's cyrtometer 328 

128. Wilson's cyrtometer applied 328 

129. Head, skull, and cerebral fissures. (Adapted from Marshall) 329 

130. Vein of the diaphragm of a septicaemic mouse. (Koch) 356 

131. Bacillus of mouse-septicaemia. (Fliigge) 357 

132. Glomerulus of a septicaemic rabbit. (Koch) 358 

133. Capillary vessels surrounding the intestinal glands of a septicaemic rabbit. (Koch) 359 

134. Bacillus of malignant oedema. (Koch) 360 

135. Spore-formation in bacillus of malignant oedema. (Fliigge) 360 

136. Cultures of bacillus of malignant oedema in gelatin. (Fliigge) 361 

137. Bacillus saprogenes 1. (Rosenbach) 366 

138. Bacillus saprogenes 2. (Rosenbach) 366 

139. Bacillus saprogenes 3. (Rosenbach) 366 

140. Proteus vulgaris. (Hauser) 367 

141. Proteus mirabilis. (Hauser) 368 

142. Involution forms of proteus mirabilis. (Hauser) 369 

143. Vessel from the cortex of the kidney of a pyasmic rabbit. (Koch) 386 

144. Suppurating thrombus in vein. (Tillmanns) 389 

145. White thrombus. (Landerer) 392 

146. Red thrombus. (Landerer) 393 

147. Laminated thrombus in a vein. (Birch-Hirschfeld) 394 

148. Thrombophlebitis. (Billroth) 395 

149. Embolus of branch of pulmonary artery. (Birch-Hirschfeld) 397 

150. Pyaemic abscess of lung. (Hamilton) 398 

151. Coagulation-necrosis from a kidney infarct. (Birch-Hirschfeld) 399 

152. Pyaemic pus. (Landerer) 403 

153. Section of ear of rabbit parallel to surface of cartilage. The morbid process resembled 

erysipelas. (Koch) 412 

154. Streptococcus erysipelatosus. (Baumgarten) 413 

155. Stab culture of streptococcus of erysipelas in gelatin. (Baumgarten) 414 

156. Section through skin near the margin of the erysipelatous zone. (Koch) 418 

157. Section of skin in erysipelas. (Cornil and Babes) 418 

158. Tetanus bacilli. (Frankel-Pfeiffer) 437 

159. Culture of bacillus tetani in nutrient gelatin. (Kitasato) 438 

160. A blood-vessel from medulla oblongata in a case of hydrophobia. (Coates) 467 

161. From the salivary gland in a case of hydrophobia. (Coates) 468 

162. Tubercle bacilli containing spores. (Koch. Colored) 478 

163. Tubercle bacilli from a tubercle cavity. (Colored) 478 

164. Giant cell with one tubercle bacillus (Fliigge) 480 

165. Giant cell. Miliary tuberculosis. (Fliigge) 480 

166. Glass-slide preparation from the tissue-juice of a fresh inoculation-tubercle. (Baum- 

garten. Colored) 480 

167. From encysted bronchial glands in miliary tuberculosis. (Koch. Colored) 480 

168. Tubercle bacilli. (Frankel and Pfeiffer. Colored) 480 

169. Vegetations of tubercle bacilli upon sterilized blood-serum. (Baumgarten. Colored) 482 



XIV LIST OF ILLUSTRATIONS. 

FIG. PAGE 

170. Inoculation-tuberculosis 487 

171. Lupous nodule situated deeply in the corium. (Colored) 495 

172. Tubercle-nodule in lymphatic gland 496 

173. Giant cell from centre of tubercle of lung. (Hamilton) 497 

174. Tuberculosis of trochanteric bursa 498 

175. Section from mucous membrane of pharynx, showing epithelioid cells with a few small 

giant cells. (Birch-Hirschfeld) 499 

176. Fully-developed reticular tubercle of lung. (Hamilton) 500 

177. Tuberculosis of trochanteric bursa 503 

178. Caseated submaxillary gland. (Colored) 504 

179. Membrane lining tubercular abscess. (Landerer) 512 

180. Senn's injection-syringe 516 

181. Tubercular lymphadenitis 530 

182. S-shaped incision in the operation for removal of tubercular glands of the neck 540 

183. Tubercular peritonitis. Parietal peritoneum. (Colored) 543 

184. Tuberculosis of the lower epiphysis of the humerus. (Sciagraph) 550 

185. Caries of fourth metacarpal bone. (Sanger Brown. Sciagraph) 554 

186. Tubercular focus near the epiphyseal line of the lower end of the femur 555 

187. Tuberculosis of astragalus. (Tillmanns) 557 

188. Tubercular sequestra. (Landerer) 557 

189. Tubercular infarct in the head of the femur. (Volkmann) 558 

190. Tubercular debris from caseated nodule. (Colored) 559 

191. Central tuberculosis of the neck of the femur. (Volkmann) 568 

192. Tuberculosis of lower epiphysis of femur. (Weber) 571 

193. Tubercular empyema of knee-joint 574 

194. Tubercular coxitis of right hip-joint. (Sciagraph) 574 

195. Knee-joints. (Albert) 576 

196. Dry tuberculosis of the shoulder-joint. (Sciagraph) 576 

197. Pathological subluxation of the hip-joint. (Sciagraph) 578 

198. Hahn's incision for arthrectomy or resection of knee-joint 583 

199. Interrupted plaster-of-Paris splint for resection of knee-joint 585 

200. Tubercle bacilli in urine. (Colored) 613 

201. Tubercle bacilli in urine. (Cornil and Babes) 614 

202. Ray-fungus. (Ponfick) 620 

203. Actinomycelial granules. (Hektoen) 621 

204. Actinomycosis of liver. (Colored) 622 

205. Actinomyces from a section of a maxillary tumor of a cow. (Crookshank. Colored) 623 

206. Actinomycelial cluster in giant cell. (Schulze) 627 

207. Giant cell with actinomycelioid cluster. (Lubarsch) 627 

208. Actinomyces. Section from actinomycotic swelling. (Flugge) 628 

209. Actinomyces from lung of cow. (Marchand) » 637 

210. Miliary abscess in the epithelium of the hand. (Hektoen) 646 

211. Three organisms more highly magnified. (Hektoen) 647 

212. An epithelial pearl. (Coates) 648 

213. Vacuolated and solid diffusely-stained organisms. (Hektoen) 649 

214. Chains of the minute form. (Hektoen) 650 

215. Development of pigment-granules. (Hektoen) 651 

216. Giant cell showing budding vacuolated organism 654 

217. Giant cells containing organisms in different stages of development 654 

218. Giant cell showing organisms apparently in sporulation-stage 655 

219. Section showing epithelial proliferation. (Herzog) 655 

220. Miliary abscess of blastomycetic dermatitis 656 

221. Anthrax bacilli. Spore-formation and spore-germination. (Koch) 660 

222. Stab culture of anthrax bacilli in gelatin. (Baumgarten) 661 

223. Anthrax colony upon gelatin. (Flugge) 663 

224. Intestinal villus of anthracic rabbit. (Koch) 664 

225. Bacillus anthracis. (Crookshank. Colored) : 665 

226. Anthrax. Section from liver. (Flugge) 672 

227. Bacilli of glanders from a young potato culture. (Baumgarten) 680 

228. Glanderous nodule from the liver of a field-mouse. (Baumgarten) 683 

229. Acute glanders. (Birch-Hirschfeld) 689 

230. Section of a glanders nodule. (Flugge. Colored) 690 



CHAPTER I. 

Regeneration. 

The student should first familiarize himself with the histological proc- 
esses as observed during the growth, development, and repair of tissues 
preparatory to a study of inflammation and the various destructive processes 
attending and following it, as in the complicated process called inflamma- 
tion attempts at repair are always manifested, and after its subsidence de- 
struction always gives way to regeneration. 

Regeneration includes a multitude of processes which are intended to 
repair the normal prrysiological waste of the tissues in the living body or 
to restore tissues lost by injury or disease. In the human body normal 
regeneration or repair of tissues is a physiological process, which is essential 
for the maintenance of the anatomical perfection and functional activity of 
the different tissues and organs. In a condition of perfect health, in the 
full-grown body, the normal waste incident to the increasing activity of the 
tissues is balanced by this reparative process, while during the development 
of the body an excess of material is added upon which depends the increase 
of tissue which constitutes growth. If cell-destruction is in excess of cell- 
reproduction atrophy is the inevitable result, and if the function of regen- 
eration is completely suspended death must necessarily ensue, the blood 
being the first tissue the seat of extreme atrophic changes, soon to be fol- 
lowed by similar changes in all the tissues, resulting in diminution of func- 
tion proportionate to the degree of atrophy, and, finally, death from maras- 
mus. 

Studied from a surgical aspect, regeneration includes the process ob- 
served in the healing of wounds produced by a trauma and the complete or 
partial restoration of parts damaged or destroyed by the action of chemical 
substances, extremes of cold and heat, and the various destructive inflam- 
matory processes caused by the presence of specific pathogenic microorgan- 
isms. Regeneration and inflammation are distinct conditions, which should 
no longer be confounded or considered from the same etiological and patho- 
logical stand-point. An ideal regeneration takes place without inflamma- 
tion provided the seat of injury or tissue-destruction remains aseptic; that 
. is, free from pathogenic microbes. On the other hand, a regenerative proc- 
ess within or around an inflammatory focus can only be established in tissues 
in which the cause which has produced the inflammation has not been suf- 
ficiently intense to destroy the protoplasm of the cells. Under these cir- 
cumstances the reparative process is initiated at a time when the cause which 

a) 



% PRINCIPLES OF SURGERY. 

has given rise to the inflammation has ceased to be active, or in tissues not 
deprived of their vegetative power by its action. In a circumscribed sup- 
purative inflammation the cells exposed to the direct action of the pus- 
microbes and their ptomaines are destroyed, and the process of repair starts 
from the abscess-walls and their immediate vicinity, from tissues which 
have retained their power of cell-proliferation. Any organ the seat of a 
tubercular infection, in which the parasitic cause is not sufficiently intense 
to destroy the vitality of the cells, retains its normal structure and function 
by virtue of this intrinsic power of regeneration of its cells. All reparative 
processes consist of homologous cell-development, and the new tissue re- 
sembles, anatomically and physiologically, the fixed cells from which it is 
produced. The legitimate succession of cells is now a well-established law 
in pathology as well as embryology, and, according to this tissue, is never 
produced by substitution of function. According to this histogenetic law, 
each cell-element possesses an intrinsic vegetative power from the earliest 
embryonal development throughout life, which, in case of loss of tissue by 
injury or disease, enables it to produce its own kind and never any other 
materially different histological structure. In conformity with this general 
law of tissue-production, an injury or defect of a nerve-fibre is repaired by 
proliferation from preexisting cells which compose this structure, epithelial 
cells are produced only by epithelial cells, new vessels are formed from cells 
which exist in a normal vessel-wall, etc. From this stand-point will be con- 
sidered: — 

I. HEALING OF WOUNDS. 

A wound may be defined as a sudden solution of continuity of any of 
the tissues of the body caused by the application of mechanical force. A 
wound is open or subcutaneous according as the surface covering the skin 
or mucous membrane has been cut or torn or has remained intact. Since 
the introduction of the antiseptic treatment of wounds, the classification 
into open and subcutaneous wounds is no longer of the same practical im- 
portance, as an open wound, under careful antiseptic treatment, is at once 
placed under the same favorable conditions for a satisfactory and rapid heal- 
ing as a subcutaneous wound. All wounds, irrespective of the anatomical 
structure of the tissues involved, heal by the production of new material 
from preexisting fixed tissue-cells. The fixed tissue-cells at the site of in- 
jury, being endowed from earliest embryonal life with a peculiar power of 
adaptation to existing conditions surrounding them, assume active tissue- 
proliferation, and the embryonal cells thus produced constitute the granula- 
tion-tissue, which, toward the completion of the healing process, is trans- 
formed into mature cells, representing the tissue or tissues which have un- 
dergone the reparative process. 



IMMEDIATE, OR DIRECT, UNION. 



IMMEDIATE, OR DIRECT, UNION. 



Since the time of John Hunter a great deal has been said and written 
on immediate, or direct, union of wounds. Hunter believed that this method 
of healing would be accomplished within a few hours, and without the in- 
terposition of new material between the accurately coaptated surfaces. Ma- 
cartney was a supporter of this view, as will be seen from the following: 
"The circumstances under which immediate union is effected are the cases 
of incised wounds that admit of being, with safety and propriety, closely and 
immediately bound up. The blood, if any be shed on the surface of the 
wound, is thus pressed out, and the divided blood-vessels and nerves are 
brought into perfect contact, and union may take place in a few hours; and, 
as no intermediate substance exists in a wound so healed, no mark or cicatrix 
is left behind/' Paget applies this method of healing to large wounds where 
rapid union is accomplished, and where, on examination, no interposed tis- 
sue is found between their edges. Such a case came under his own observa- 
tion. A patient on whom he had performed an operation for the removal 
of a carcinomatous breast died from an attack of erysipelas a few days later. 
Examination showed that firm union had taken place apparently without 
any intermediate material. He also made three experiments on rabbits for 
the purpose of studying this rapid method of repair. The hair was removed, 
the skin incised, and the wound accurately sutured. Three days later he 
examined the parts, and found the wound quite firmly united, without any 
macroscopical evidences of inflammation. On microscopical examination he 
found some exudation material in the immediate vicinity of the wound. 

Among the more modern investigators, we find Thiersch still uphold- 
ing the possibility of immediate union by direct cohesion of similar parts. 
He studied the repair of wounds in the tongue of guinea-pigs. The tongue 
was incised in a longitudinal direction, and the parts were examined a few 
hours to several days after the injury had been inflicted. Before sections 
were made for microscopical examination the lingual vessels were injected 
with liquid glue stained with carmine. In specimens where the wound was 
only a few hours old he found, at least, parts of the wound firmly adherent, 
and on microscopical examination he satisfied himself that the connective 
tissue, saturated with blood and plasma, had formed an immediate and per- 
manent union. He described also a plasmatic circulation in the wound 
which he considered of great importance for the nutrition of the tissues. 
He believed that these new channels, by becoming paved with the adjacent 
connective cells, could be transformed into permanent blood-vessels. 

The same section examined under a higher power furnishes a good 
illustration of the part taken by the fixed tissue-cell in the repair of the 
wound. 



4 



PRINCIPLES OF SURGERY. 



Some surgeons still believe in immediate union in the repair of wounds 
of nerves, as many cases have been reported where complete restoration of 
function was claimed to have been established within a few hours after nerve- 
suture. Such observations are not 
free from criticism, because func- 
tional results after nerve-suture 
may lead to wrong conclusions, as 
restoration of function in distal 
parts may be owed to the presence 
of other nerves which reach such 
parts, and it may be due partly to 
physical conduction of irritation. 
The occurrence of immediate union 
was doubted by O'Halleran, a dis- 
tinguished contemporary of Bell, as 
may be learned from the following 





Fig. 1. — A Wound Twenty-six Hours Old. A, coaptated parts apparently united. 
Tissues only slightly stained with coloring material of blood; few leucocytes. B, B, 
spaces between wound-surfaces filled with red and white blood-corpuscles, some of the 
former well preserved, others showing various degrees of disintegration; between them, 
cedematous connective-tissue fibres. C, C show that these fibres are continuous with the 
connective tissue of the wound-surfaces. Surface of wound coaptation imperfect; the 
epithelial cells dip down into the wound. D, a separated cone of new tissue. B, infil- 
tration of fatty tissue with blood and leucocytes. O, divided muscular fibres, with 
escaped pieces which have partly undergone colloid degeneration. (Hartnack, obj. 4, 
oc. 2.) {Thiersch.) 



quotation: "I would ask the most ignorant tyro in our profession whether 
he ever saw, or heard even, of a wound, though no more than one inch long, 
united in so short a time," adding: "These tales are told with more con- 
fidence than veracity; healing by inosculation, by the first intention, by 



IM ME I) I ATE, Oil DIHECT, UNION. O 

immediate coalescence without suppuration is merely chimerical and opposite 
to the rules of nature." 

Gussenbauer repeated the experiments of Thiersch and Wywodzoff on 
the healing of wounds in the tongue of guinea-pigs, and came to entirely 
different conclusions. In wounds eight to twelve hours old he found that 
the margins formed an elliptical space, the separation being widest in the 
middle. The divided muscular fibres had retracted, imparting to the wound 
an uneven surface, which was covered with a layer of reddish, gelatinous 
material. In recent wounds the space is filled with blood-corpuscles which 




Fig. 2.— A, embryonal cells showing karyokinetic figures; B, lymph-spaces; C, 
striped masses infiltrated with red blood-corpuscles in various stages of disintegration; 
D, blood-vessel; F, fat-tissue. (Hartnack, obj. 8, oc. 4.) (Thiersch.) 



are often much changed in color, size, and shape. In wounds twenty-four 
to forty-eight hours old the material between the surfaces of the wound 
presented a reticulated appearance, each one of the spaces corresponding to 
a blood-vessel. Contrary to Thiersch, he asserts that in this substance no 
connective tissue can be found; the reticulated structure he attributed to 
the presence of fibrin, the coagulum infiltrating at the same time the ad- 
jacent tissues. He believes that the parenchyma-fluid takes part in the 
formation of the coagulum. He was unable to verify, by his own observa- 
tions, the existence of the plasma-channels described by Thiersch. When 
the wound-surfaces were kept accurately approximated he found few blood- 



6 PRINCIPLES OF SURGERY. 

corpuscles, but the net-work of fibrin was never absent. In harelip opera- 
tions and incised wounds of the face and scalp, if uninterrupted apposition 
is maintained for a day or two, the parts are found so firmly glued together 
that the belief that immediate union had taken place might still be main- 
tained from a superficial examination, but a microscopical examination will 
always reveal the conditions described by Gussenbauer, and the union is 
therefore only apparent, and not real. The surfaces of the wound have be- 
come adherent by the interposition of an adhesive material. A certain 
amount of coagulation-necrosis takes place in every wound, and the mate- 
rial thus formed serves as a cement-substance which temporarily glues the 
parts together. This mechanical union, the result of destructive chemical 
changes in the extravasated blood, is the form of union which has been 
wrongly interpreted and described as immediate union. This primary ad- 
hesion occurs most readily in wounds of dense vascular tissue and where 
approximation and fixation of the edges of the wound are most thoroughly 
secured, — conditions which favor the subsequent definitive healing of the 
wound by the interposition of new tissue. 

UNION BY PRIMARY INTENTION. 

Organic union, the union aimed at in the treatment of all wounds, is 
only obtained by tissue-proliferation from the fixed cells of the injured 
parts, and is completed only after restoration of the continuity of the divided 
structures, and the return, partial or complete, of the functions suspended 
by the injury or disease. Eeturn of structure and function to an at least 
approximately normal standard implies a return of the interrupted circula- 
tion by the formation of new blood-vessels; in other words, organic union 
cannot be said to have taken place without an adequate supply of new blood- 
vessels in the new tissue which form a capillary collateral net-work be- 
tween the divided blood-vessels. Such a union, even under the most favor- 
able circumstances, cannot be established in less than six to eight days, 
and its attainment may require weeks and months. The next method of 
repair described by John Hunter was union by adhesive inflammation. Ab- 
sence of suppuration and rapid union have always been considered as essential 
features of this mode of healing, and corresponds to the healing of wounds 
per primam intentionem, — an expression which, for obvious reasons, has been 
retained in modern literature to distinguish it from the method of healing 
per secundem intentionem, where the reparative process is often indefinitely 
delayed by suppuration. All wounds which heal without suppuration heal 
by primary union, either ivitliout or with visible granulation-tissue. An 
ideal result is obtained if the separated surfaces unite throughout and the 
repair in the depth of the wound is accomplished during the same time un- 



KARYOKINESIS. 7 

derneath the united skin or mucous membrane. If there has been a con- 
siderable loss of surface tissue and the superficial portion of the wound can- 
not be approximated, or, if rapid healing at the surface of the wound fails 
to take place, the wound heals slowly by the formation of a larger amount 
of granulation-tissue, and yet, if suppuration does not complicate the process, 
it must be said that the wound has healed by primary union. This method 
of healing was exceedingly rare before antiseptic surgery was practiced, but 
since that time it is of frequent occurrence. All wounds which heal without 
suppuration heal without inflammation. All inflamed wounds suppurate; 
the reparative process is delayed until the inflammation has subsided. The 
proper modern classification of wounds in reference to the method of repair 
consists in a distinction between (1) aseptic wounds and (2) infected wounds. 
Aseptic wounds — that is, wounds not contaminated with pathogenic microor- 
ganisms — heal without inflammation. An aseptic wound, as a rule, is pain- 
less, and does not present any of the other witnesses of inflammation. The 
slight swelling and, perhaps, redness are the result of mechanical disturb- 
ances of the circulation, and subside with the formation of an adequate col- 
lateral circulation; hence, from an etiological and pathological point of 
view, we have no legitimate right to apply the term inflammation to such 
a method of repair. Koenig makes the statement that the product of tis- 
sue-proliferation in the healing of an aseptic wound is not in excess of the 
local demand; hence, the process is purely one of regeneration, and not 
inflammation. Hueter was one of the first who insisted on limiting the 
meaning of the term inflammation, which he wished to have applied only 
to destructive processes caused by the action of specific microbes. In an 
aseptic wound the fixed tissue-cells assume tissue-proliferation, by virtue of 
their intrinsic vegetative power, within a few hours after the injury has 
been inflicted, and all the permanent material utilized in the process of re- 
pair is derived from this source. The leucocytes serve a useful purpose in 
the temporary closure of divided capillary vessels and in the formation of 
the temporary cement-substance by which the surfaces of the wound are 
mechanically glued together, and, lastly, as food for the embryonal cells, 
but they take no active part in the production of new tissue. 

In studying the process of healing in wounds as well as in the consid- 
eration of regeneration in general, it is of the greatest importance to become 
familiar with the histological changes which precede and attend the forma- 
tion of new tissue; hence, in this connection should be given a description 
of 

KARYOKIN"ESIS. 

Karyokinesis, or karyomitosis, as described by Flemming, is the in- 
direct reproduction of cells as compared with direct cell-division by seg- 



8 PRINCIPLES OF SURGERY. 

mentation. It is a process by which the net-work of chromatin threads 
within the nucleus undergoes great development, and is subject to certain 
transformations of form, which are instrumental in effecting division of 
nucleus and cell. The term karyokinesis was first used by Schleicher, and 
the first accurate description of the process, as seen in the cells of a number 
of animals, simple in form and structure, was given by Butschli in 1876. 
The modern definition of a cell is much more complicated than that given 
by Schleiden and Schwann, as recent researches have shown that it is not 
such a simple structure as it was formerly believed to be. When we speak 
of a cell now we mean a mass of circumscribed living substance, with or with- 
out an envelope, which contains as an essential element in its interior a 
nucleus, with the property of forming new compounds out of substances 
taken into it, and is capable of reproduction by division. Both the nucleus 
and cell are composed of threads and intermediate substance. The cell- 





Fig. 4. 

Fig. 3.— Quiescent Nucleus. Epithelial Cell of Salamander Entering upon the 
"Glomerular" Phase. (Flemming.) 
Fig. 4.— Living Cell of Salamander. A, granules aggregated round a pole of the cell; 
B, coils of "glomerular" net- work; C, cell-body. (Flemming.) 

body consists of threads somewhat irregularly distributed, seldom forming 
a net-work, imbedded in a homogeneous substance. The nuclear threads 
stain with hematoxylin and safranin, and hence are called chromatin 
threads, which are arranged in a net-like figure, the meshes of which are 
filled with a substance which cannot be stained, and hence is named by 
Flemming achromatin. The nucleus is surrounded by a membrane com- 
posed of two layers; the inner can be stained, but not the outer. The 
nucleoli, usually multiple, are made up of a substance more refractile than 
the structures described in the nucleus. They are round and smooth, and 
either suspended in the net-work or between the threads. The nucleus in 
a cell that is not in a condition of functional activity is said to be in a quies- 
cent or resting state. 

At this time the chromatin threads become transformed into a sort of 
skein, formed apparently of one long, convoluted thread; the inner layer 



KARYOKINESIS. V 

of the nuclear membrane and nucleoli disappear, or are incorporated into 
the achromatin substance of the nucleus. The development of the net-work 
of the chromatin substance in the nucleus undergoes five phases until com- 
plete division of the nucleus and cell has been effected. 

Phase I. The first change indicative of beginning karyokinesis, accord- 
ing to Flemming, is the formation within the cell-protoplasm of two poles 
opposite to each other and near the nucleus. 

The next change noticed is that in the nucleus: the chromatin threads 
become plainer, thicker, and more convoluted. This increase of chromatin 
substance is the result of longitudinal splitting of its threads. The achro- 
matin layer of the nuclear envelope increases in thickness, while the inner 
layer has become a part of the chromatin net -work. 

Phase II. During this stage the chromatin threads are drawn out into 




Fig. 5.— Endothelial Cells; Abdomen of Salamander. 1. Surface view of nuclear 
net-work; A, cell-body; B, threads of net- work; G, one of the poles with the achro- 
matin threads radiating from it. 2. Equatorial view of a corresponding cell; A, one of 
the poles; B,' the nuclear net- work seen on edge; C, the achromatin threads forming 
a spindle between the poles. (Flemming.) 

loops with long limbs. This arrangement imparts to the looped net-work 
the figure of an aster, or star. 

In the middle of the star is a clear space, which does not stain and is 
occupied by achromatin substance. In animal cells the greater portion of 
the space within the nuclear membrane is filled with chromatin threads, 
while in vegetable cells the achromatin substance predominates. The 
nuclear spindle in the centre of the achromatin substance (Fig. 4, (7), ac- 
cording to Strassburger and Biitschli, consists of fine, colorless fibres, which 
do not stain at all, or only slightly, by using special nucleus-staining re- 
agents, and on this account the achromatin threads probably contain no 
nuclein. 

Phase III. The star-shaped mass of nuclear threads divides into two 
equal portions, with the angles of the loops to the poles, and their limbs 
partly obliquely, partly perpendicularly to the equator of the nucleus. 



10 



PRINCIPLES OF SURGERY. 



The equatorial disk is formed in this manner, and indicates the com- 
pletion of this phase. 

Phase IV. This phase begins with a separation of the threads at the 
equator, and ends with concentration of the threads in each polar segment 
of the cell. 

As the number of loops in each segment is the same as in the old nucleus, 
it may be conjectured that the halves of each thread separate into the two 
daughter-stars. 

Phase V. The threads in the daughter-nucleus form a wreath, after 
which they contract more and more until the undivided convolutions can 
hardly be recognized. 

A nuclear membrane again appears, after which the net-work returns 
to its quiescent state. 





Fig. 6. 



Fig. 7. 



Fig. 6. — Epithelial Cell of Salamander. A, pole and achromatin threads; B, cell-body.; 
C, disk-like arrangement of chromatin threads at equator of nucleus. (Flemming.) 
Fig. 7. — Epithelial Cell of Salamander. A, A', chromatin threads of daughter-stars; 
B, achromatin threads and pole. (Flemming.) 

There is a strong tendency at the present time to refer all karyokinetic 
changes to the agency of the nucleus, and to ascribe to the protoplasm of 
the cell the passive role of a nutritive substance. In the impregnated ovum 
the influence of nuclear changes has been described, but at the same time 
it was shown that the protoplasm of the cell is capable of automatic as well 
as responsive action. Pfltiger asserted that gravitation is the sole guiding 
agency in the process of cleavage of protoplasm. According to Born, Herturg, 
Weismann, and Kolliker, the protoplasm alone is isotropic, but Whitman 
thinks that this is far from the truth. Others, like Pflueger, believe that 
the protoplasm contains physiological molecules from which organs are de- 
veloped. Polarity of cell-protoplasm and in nucleus exists independently, 
and is not reciprocal. Contractions in unfertilized ova have been observed. 
M. Nussbaum was first to prove that enucleated fragments of an infusorium 
are incapable of reproduction, while parts of an infusorium containing a 



K AKYOKIXESIS. 



11 



nucleus possessed this power. This would tend to establish the fact that 
the nucleus is indispensable to the preservation of the vegetative energy of 
the cell. On the other hand, Gruber, in one of his experiments, divided a 
stentor before fission had taken place in such a manner that the sections 
contained no nuclear substance, and yet the next day each one of these parts 
represented a complete stentor. Against the conclusions drawn from this 
experiment it might be urged that some of the nuclear chromatin threads 
might have found their way into the cell-protoplasm, and that from them 
the process of reproduction started. Xussbaum regards a combination of 
nuclear structure and cell-protoplasm as essential for cell-production. Ac- 




Fig. 8.- 



-Epithelial Cell of Salamander. A. A', daughter-glomeruli; B, achromatin 
threads still uniting the two daughter-cells. (Flemming.) 



cording to Flemming, the cell-body begins to divide toward the end of the 
fourth phase of karyokinesis. Cell-division commences with a constriction 
at the equator, which becomes deeper and deeper as the daughter-cells as- 
sume cell form, until complete segmentation takes place. Toward the com- 
pletion of the separation only a few achromatin threads (Fig. 8, B) connect 
the two. To Flemming belongs the credit of having first discovered karyo- 
kinetic changes in cells undergoing division, but our knowledge of this sub- 
ject has been greatly advanced by the combined labors of Strassburger, 
Arnold, Klebs, and Whitman. Arnold studied this method of cell-division 
in giant cells of the medulla and in the blood-corpuscles of leukaemic blood. 



12 PRINCIPLES OF SURGERY. 

He preserved the blood-corpuscles in a 6-per-cent. methyl-green salt-solu- 
tion, which preserves cells in a good condition if the solution is kept at a 
proper temperature in the moist chamber on the object-glass. If to this 
solution a 25-per-cent. solution of chloride of gold is added, the karyokinetic 
figures are made clearer. In studying the process of karyokinesis in fixed 
tissue-cells in a state of proliferation, it is necessary to resort to the fixation 
and staining methods described by Flemming. The modern observers who 
have studied regeneration of epithelial cells have come to the conclusion that 
cell-division takes place almost exclusively by karyokinesis. Podwyssozki 
has studied this method of cell-reproduction with special reference to regen- 
eration of liver-cells, and has come to some very important conclusions. In 
cats and young guinea-pigs he observed, after injury of the liver, extra- 
nuclear chromatin substance before he could detect any karoykinetic figures 
in the nucleus. The chromatin in the cell-body appeared in two forms: 
either as fine granules scattered diffusely through the protoplasm of the cell 
or as lumps of chromatin, and he designated these larger masses as pro- 
chromatin; but he also noticed that the granular form, at a later stage, 
aggregated and formed masses which united with the nuclear chromatin. 
Klebs explains the presence of chromatin in the cell-protoplasm to an extra- 
cellular origin: the leucocytes. He believes that the chromatin contained 
in leucocytes is liberated after fragmentation has taken place and enters the 
young cells, where they serve as food and become a part of the nuclear net- 
work. This view is strengthened by the statement of Podwyssozki that he 
found numerous leucocytes in the immediate vicinity of the new cells. 
Ziegler and Obolensky produced arsenical intoxication in animals by ad- 
ministering the drug in daily doses subcutaneously, and when they examined 
the liver they found well-marked karyokinetic figures in the endothelial cells 
of the intraacinous capillaries, the epithelia of the bile-ducts, and, less fre- 
quently, in the secreting cells. Karyokinetic figures were first visible in the 
nuclei of the capillary endothelia, and were undoubtedly caused by the direct 
action of the arsenic upon the cells. These experiments show that karyo- 
kinesis will follow the application of chemical, as well as traumatic, irritants. 



FRAGMENTATION OF NUCLEUS. 

Arnold and Pfitzner have described, in giant and other cells under- 
going pathological changes, direct fragmentary division of the nucleus, by 
which it may break up into many parts, often of unequal size, without con- 
temporaneous division of the cell. Arnold and others have also described 
incomplete fragmentation of the nucleus where the nuclear masses remain 
connected with each other, and can be seen as lobulated and reticulated 
structures. Arnold saw fragmentation of the nucleus in the cells of the 



ORANULATION-TISStJE. 13 

marrow of bone and in Leucocytes undergoing transformation into pus-cor- 
puscles. A nucleus which undergoes fragmentation contains but little 
chromatin substance, and is therefore incapable of multiplication by karyo- 
kinesis; and such cells, according to the investigations of Klebs, never take 
an active part in the regeneration of tissue. 

DIRECT CELL-DIVISION. 

In 1841 Martin Barry first made the observation that the division of 
cells was accompanied with division of the nucleus, and for a long time it 
was believed that this process is simply a segmentation of the nucleus, fol- 
lowed by division of the whole cell. Eemak taught that direct division com- 
menced in the nucleolus, extended to the nucleus, and finally resulted in 
fission of the cell-body, each of the new r cells containing a daughter-nucleus. 

According to Pfitzner, direct cell-division is a more frequent method of 
cell-multiplication than the indirect in young animals where cell-prolifera- 
tion is rapid. In the embryo the nucleus contains but little chromatin, and 
therefore the karyokinetic figures are less abundant. 






A 8 c p 

Fig. 9. — A, mature cell; B, commencing division of nucleus and contraction of cell- 
protoplasm in the centre; C, complete division of nucleus and cell; D, formation of two 
new cells. (McKendrick.) 

In most of the regenerative processes in mature tissue-cells reproduc- 
tion takes place by karyokinesis, and only in exceptional instances by direct 
division. The new T cellular elements present karyokinetic figures in all 
stages, and wherever these are seen it is a positive evidence that the fixed tissue- 
cells are the seat of tissue-proliferation, and that wounds are healed and defects 
repaired exclusively by this method of cell-formation. 

GRANULATION-TISSUE. 

The new 7 cells formed by indirect or direct cell-division in a w T ounded 
or injured part, the seat of regenerative processes, constitute the granula- 
tion-tissue as long as they remain in their embryonal state. As immediate 
union never takes place in any part or tissue of the body, we are forced to 
admit that every wound heals only by the interposition between the divided 
parts of a greater or less amount of granulation-tissue. If the wound remain 
aseptic, and the surfaces of the wound are kept in accurate coaptation, the 
healing is accomplished in a short time, and by the production of a mini- 
mum amount of new tissue. A similar wound, with great loss of tissue pre- 



14 



PRINCIPLES OF SURGERY. 



eluding the possibility of bringing the parts in apposition by mechanical 
resources, must necessarily heal by the production of a large quantity of 
granulation-tissue, the process of repair in both instances being the same, 
the difference being mainly the length of time required to complete the heal- 
ing process and the amount of new material necessary for this purpose. In 
the first case the wound heals without visible granulation-tissue; in the 
latter the defect becomes covered with granulations before the wound can 
heal. The macroscopical and microscopical appearances of granulating sur- 
faces are nearly identical in all the tissues. A bone covered with granula- 
tions looks the same as a granulating surface of any of the soft tissues. Even 




Fig. 10. — Granulating Wound. Capillary Loons Surrounded by Embryonal Cells. 
X 300-400. (Billroth-Winiwarter.) 



the embryonal cells of which the granulations are covered, so long as they 
remain in this state, furnish, from their microscopical appearances, only re- 
mote or no indications as to their histogenetic source and ultimate destina- 
tion. Differentiation takes place during their further development toward 
the completion of the healing process. The bulk of all granulation-tissue is 
derived from the connective tissue, as this mesoblastic structure is diffused 
throughout the entire body, and, with the exception of the nervous system, 
is found in almost every organ. In the nervous system it is represented by 
an almost similar tissue, — the neuroglia, — which performs the same role 
in the repair of injuries and defects of the brain and spinal cord. A wound 



GRANULATION-TISSUE. 



15 



or defect covered with granulations presents a velvety appearance, each tuft 
or papilla representing a separate loop or net-work of new capillary vessels. 
The new capillary vessels are paved with endothelial cells containing 
a very large nucleus. Sometimes a single capillary vessel enters a papilla 
and gives off a number of branches, which form a net-work of convoluted 
vessels, rendering the granulations exceedingly vascular and liable to bleed 
on the slightest provocation. 




Fig. 11. — Granulation-tissue from Wound. Blood-vessels Injected. X 400. A, 
capillary loops with several branches; B, ordinary granulation-cells; C, fibroblasts; 
stroma. (Hamilton.) 



The blood in the tuft is collected and returned usually through one 
vein. Emigration of leucocytes through the walls of the new capillary ves- 
sels is a common occurrence, and, when they reach the surface, form one 
of the elements of secretion of the wound. When the capillary vessels are 
imperfectly developed, or when they are in a state of inflammation, the ex- 
udation becomes profuse and the granulation-surface becomes covered with 
a membrane consisting of the products of coagulation-necrosis. Wounds 



16 PRINCIPLES OF SURGERY. 

presenting such, an appearance have frequently been mistaken as an evidence 
of diphtheritic infection. The so-called healthy granulations are small, 
firm, and of a pinkish-red color, and the surface from which they spring is 
only moistened with colorless, viscid fluid. Wounds covered with such gran- 
ulations heal rapidly and leave a small, pliable cicatrix. Profuse flabby and 
pale granulations indicate a want of general vitality, or more frequently the 
presence of pathogenic microbes, which act injuriously upon the process of 
transition of embryonal cells into tissue of a higher type. Such granulations 
are frequently met with in wounds after imperfect operations for tubercular 
lesions, in suppurating wounds, and in ulcers of the lower extremities, where 
the vascular conditions are unfavorable for the growth and development 
of new tissue. Histologically granulation-tissue is composed of a delicate, 
(Edematous reticulum, and upon its fibres can be seen numerous connective- 
tissue corpuscles. The reticulum is intimately connected with the blood- 
vessels, and in its meshes are contained the embryonal cells and leucocytes, 
the latter serving as food for the former. The embryonal connective-tissue 
cells are about two or three times larger than the leucocytes. The giant cells 
which are occasionally found are fibroblasts which have grown to such enor- 
mous proportions by inclusion of nutritive material derived from disin- 
tegrating leucocytes. 

VASCULARIZATION OF GRANULATION-TISSUE. 

The vessels which furnish the blood-supply to the granulation-tissue 
are new structures, and are usually formed from preexisting vessels in in- 
jured vascular tissue, and from the nearest blood-vessels in non-vascular tis- 
sue. Yessel-formation and tissue-proliferation are initiated simultaneously, 
and keep pace with each other until the necessary amount of granulation- 
tissue has been produced, when, during the transformation of the embryonal 
cells into permanent tissue, the vascular supply is gradually diminished by 
the obliteration and disappearance of all of the superfluous vessels. As the 
layer of granulation-tissue seldom exceeds more than 1 / 8 inch in thickness, 
the new vessels always remain short, and retain their communication with 
the preexisting vessels from which they started. Travers, in his experiments 
on injuries of the frog's web, has observed that the blood in the divided ves- 
sels becomes stagnant some little distance from the wound. During this 
time material oozes from the cut vessels, which constitutes the primary 
wound-secretion. Before granulations can be established the circulation 
must become restored by enlargement and multiplication of preformed 
vessels. 

The capillary vessels which have been cut or otherwise injured are 
closed with Nature's haemostatic: a minute thrombus. The intravascular 
pressure on the proximal side of the obstruction results in dilatation of the 



VASCULARIZATION OF GRANULATION-TISSUE. 



17 



vessel, which produces an increased blood-supply to the part commensurate 
with the increased demand for nutritive material. The new blood-vessels 
are formed by angioblasts, which are proliferated from preexisting vascular 
structures. Arnold has studied the formation of new blood-vessels in the 
stump of the tail of tadpoles after amputation, and in keratitis vasculosa 
artificially produced in the cornea of rabbits. To the researches of this au- 
thor we owe most of the knowledge we possess on this subject. The new 
vessels are produced by the budding process from capillaries near the surface 
of the wound. The bud appears first as a circumscribed thickening of the 
capillary wall, which soon projects outward in the form of a triangular eel- 




Fig. 12.— Superficial Capillaries of a Wound Beginning to Granulate, about Forty- 
eight Hours after its Infliction. X 350. A, free surface; B, the capillary loops all dis- 
tended with blood, and being driven outward in tortuous festoons; C, embryonal cells. 
(Hamilton.) 

hilar mass composed of angioblasts. The bud is then transformed into a 
long string, terminating in a delicate granular thread. 

The base of such a projection becomes excavated, and blood enters from 
the vessel to which it is attached. When the terminal ends of two of such 
projections meet they unite and form an arch, which, after they have be- 
come permeable to the blood-current, constitute a capillary loop from which 
branches again may develop in the same manner. The new channels con- 
tain, upon their inner surfaces, nuclei at variable distances, which subse- 
quently undergo transformation into endothelial cells. The adventitia is 
formed by round cells, which arrange themselves along the outer surface of 
the new channels. Hunter maintained that blood-vessels are formed in 



18 PRINCIPLES OF SURGERY. 

granulations independently of preexisting vessels, in the same manner as 
in the embryo, and that they enter into communication with the vascular 
system subsequently. Such a method of vascularization during post-em- 
bryonic life is not proved. A number of pathologists, and among them Bill- 
roth, still believe that blood-corpuscles and blood-vessels can be produced 
from connective tissue. They claim that connective-tissue cells in the inter- 
capillary spaces enlarge, become branched, and that by union between similar 
projections between two or more cells hollow spaces are created which serve 
as blood-vessels, while the nucleus assumes the role of an rraemapoietic organ: 
a process which is well illustrated by Fig. 14. 

Still another method of vessel-formation in granulations has been ob- 
served and described by Travers. He noticed that, when one of the new 
capillary vessels ruptures and blood is poured out into the granulation- 
tissue, among the embryonal cells a vascular space without walls is formed. 
The extravasated blood, under these circumstances, did not disintegrate, and 







Fig. 13. — Formation of New Blood-vessels by Budding. A, after three hours; 
B, after six hours. {Arnold.) 

as soon as the space came in contact with another capillary loop the wall 
gave way and a communication was established between the two capillary 
vessels, and later the channel became lined with endothelial cells. This 
method of vessel-formation is termed canalization. While the possibility 
of the development of new vessels independently of preformed blood-vessels 
cannot be denied, such an origin is, to say the least, exceedingly rare, and 
for all practical purposes, when we speak of vascularization of granulation- 
tissue or the formation of new blood-vessels in general, we mean the forma- 
tion of new channels by tissue-proliferation from the walls of preexisting 
blood-vessels. D. J. Hamilton, author of the excellent "Text-book of 
Pathology," asserts that the blood-vessels in granulation-tissue are not new, 
but dilated, tortuous, preformed vessels. 

In wounds that heal rapidly the existence of most of the new blood- 
vessels is a short one. With the beginning of cicatrization they disappear 
rapidly, and comparatively only a few of them remain as permanent struct- 



CICATRIZATION. 



19 



ures as a system of collateral vessels which restore indirectly the loss of con- 
tinuity between the divided vessels. A failure of the vessels to disappear 
after cicatrization has been completed usually is an indication that some 
pathogenic microorganisms have become imbedded in the scar-tissue, which 
interfere with the proper and prompt transformation of embryonal into per- 
manent tissue. Such scars are often met with after operations for tubercular 
lesions and after the healing of extensive burns, being caused, in the first 
instance, by the bacillus of tuberculosis and in the latter by pus-microbes. 
The vascular conditions in granulating surfaces should be carefully studied, 
and in the treatment due attention should be given to this important point, 
as compression and position are potent measures in improving a faulty cir- 
culation, which may have indefinitely retarded the healing process. 




Fig. 14. — Development of Blood-corpuscles in Connective-Tissue Cells, and Trans- 
formation of the Latter into Capillary Blood-vessels. A, an elongated cell with a cavity 
in its protoplasm occupied by fluid and by blood-corpuscles; B, a hollow cell, the nucleus 
of which has been multiplied; the new nuclei are arranged around the wall of the cav- 
ity, the corpuscles in which have now become discoid; C, shows the mode of union of 
a "hsemapoietic" cell, which, in this instance, contains only one corpuscle, with the pro- 
longation (BL) of a previously existing vessel. A and C, from the newborn rat; B, 
from foetal sheep. (Fluegge.) 

CICATRIZATION. 

The process of transformation of the embryonal cells in granulation- 
tissue into permanent, fixed tissue-cells is called cicatrization. Sir James 
Paget well said that during the stage of the healing process a life of eminence 
is changed into one of longevity. In tissues endowed with great vegetative 
powers and a high degree of adaptation, even large defects are replaced by 
tissue which resembles to perfection — anatomically, histologically, and phys- 
iologically — the injured preexisting tissue. This is the case in injuries in- 
volving considerable loss of substance in bone, tendons, and peripheral 



20 



PRINCIPLES OF SURGERY. 



nerves. Complete restoration of a peripheral nerve frequently takes place 
after resection of more than an inch of its continuity. In subcutaneous 



W^MhSik^ 




Fig. 15. — Granulating Wound Undergoing Cicatrization. A, vessel with numerous 
lateral branches; granulation-cells not much changed, only few spindle cells near the 
main trunk; B, cicatrization farther advanced; spindle cells predominate; C, D, D', 
cicatrization well advanced; E, E', epithelial cells; F, hair-follicle with proliferation 
of epithelial cells in its interior, new cells reaching the surface, G. (Landerer.) 



CICATRIZATION. 



21 



tenotomy the tendon-ends may be kept separated for two or more inches, 
and yet after a few months it would be difficult to ascertain, even after the 
most careful examination, the site of operation. The fractured ends of a 
broken bone may be completely separated by lateral displacement during the 
entire time required in the healing process, and yet they are firmly united 
by the interposition of a connecting bridge of new bone. In other tissues 
endowed with less reparative energy, as — for instance — the muscular fibre, 
a slight separation results in the formation of cicatricial tissue between the 
anatomical structure which it is the intention to unite. By cicatrization is 
therefore understood the completion of the reparative process, and the term 
does not necessarily imply the formation of a permanent cicatrix. An ideal 
healing culminates in the formation of tissue which effects a physiological 
restitution of a defect caused by injury or disease. As a rule, it can be stated 




Fig. 16. — Embryonal Connective-Tissue Cell Undergoing Transformation into Mature 
State. A, the cell-body; still contains a considerable amount of protoplasm, which, how- 
ever, gradually diminishes toward D, where it represents a mature connective-tissue cell 
with a very small amount of protoplasm surrounded by connective-tissue fibres. 
(Ziegler.) 

that the result will be satisfactory in proportion to the amount of granula- 
tion-tissue produced or required in the process of repair. In an aseptic 
wound the reparative material will not be in excess of the local demand, 
and the demand will depend on the degree of accuracy of approximation 
of the surfaces of the wound. Cicatrization begins in the granulation-tissue 
nearest the preformed vessel; that is, the margins and surface of the wound. 

The embryonal connective-tissue cells, or fibroblasts, as they are called, 
at first round, become elongated with thread-like prolongations from the 
extremities. (Fig. 16.) 

The new connective tissue contracts, thus bringing the margins of the 
wound or granulating surface in closer apposition, and by its constricting 
effect assisting in the obliteration of superfluous vessels. The cicatrix or 
scar will be large if the process of granulation has been in excess of the de- 
mand, or if a large defect had to be healed by the deposition or interposition 



22 PRINCIPLES OF SURGERY. 

of a large quantity of cicatricial material. Large scars should be prevented, 
if possible, by appropriate treatment, as from the contraction they give rise 
to distressing deformities, and from their low vitality they fnrnish a per- 
manent predisposition to ulcerative processes and not infrequently become 
the seat of malignant disease. After the healing of any ulcer of considerable 
size upon the mucous surface of any of the hollow viscera the cicatricial con- 
traction often gives rise to the formation of strictures. Nerves appear to 
form in granulations, as these are often exceedingly tender to the touch. 
Their existence, however, has not been demonstrated. The pain and tender- 
ness may be caused by force being transmitted to subjacent nerves. Accord- 
ing to Van der Kolk, no lymphatic vessels are present in granulation-tissue. 



r 



~ " (=1 ' ■T~^ry^~i' :v ' m ""7 



Y M 

iii 1 ' \ 

;■• 1 \ 




MMW : T , : f*j. 



Fig. 17. — Wandering Epithelial Cells from Frog. A, old epithelial cells upon edge of 
wound of skin, with proliferation of nucleus. (Klebs.) 

During the process of cicatrization all the embryonal cell-elements undergo 
transformation into mature tissue, the fibroblasts are converted into con- 
nective tissue, the angioblasts into vessels, the myoblasts into muscle-fibres, 
the osteoblasts into bone, etc., each histological element represented in the 
wound or defect furnishing the material for its own repair. 

EPIDERMIZATION. 

A wound of the external surface of the body can be said to have healed 
after the completion of epidermization. In accordance with the general law 
of succession of cells, epidermization takes place exclusively by proliferation 
of preformed epithelial cells. The new epithelial cells have a more or less 
rounded shape, and cover the granulations from the margins of the wound, 
where the new skin appears as a bluish-pink pellicle. At first they do not 



POSITIVE INDICATIONS IN THE TREATMENT OF WOUNDS. 23 

readily adhere to the granulations, but appear to cover them (Fig. 15, E')\ 
later, however, they throw down long processes which penetrate the granu- 
lations, and in this way obtain a permanent foot-hold. New epithelial cells 
possess amcebid movements, may become detached from the epithelial matrix, 
and wander some distance and form permanent attachments, and in such an 
event an independent centre of epidermization is established. Migration of 
epithelial cells was first observed and described by Klebs in superficial 
wounds in the skin of the frog. (Fig. 17.) The irregular projections of the 
new skin over the granulations, so frequently observed during the healing 
of wounds by granulation, is undoubtedly often due to such a displacement 
of embryonal epithelial cells. In granulating surfaces following destruction 
of the skin by burns, caustics, or ulceration, independent centres of epi- 
dermization are often seen in the midst of the field of granulations. In such 
cases the entire thickness of the skin at some points has not been destroyed, 
and epithelial proliferation takes place from remaining remnants of glands, 
as is well shown at F and G in Fig. 15. The granulations in the immediate 
vicinity of the zone of epidermization become reduced in size, the blood- 
vessels are diminished in number, and the subjacent fibroblasts are rapidly 
converted into connective tissue. In wounds of the skin which heal without 
visible granulations the papillse are absent from the cicatrix, even though it 
be broad from subsequent yielding to traction. In wounds healing by open 
granulations new papillae are formed in the new skin, because the capillary 
loops atrophy downward and become the papillary vessels. Epidermization 
and cicatrization are favorably influenced by measures which secure for the 
wound an aseptic condition throughout, and by keeping the delicate granula- 
tions covered with protective silk until the wound is completely healed. 



POSITIVE INDICATIONS IN THE TREATMENT OP WOUNDS, WITH SPECIAL 
REFERENCE TO SECURE UNION BY FIRST INTENTION. 

Absolute Asepsis. — Absolute asepsis can only be secured by strictest anti- 
septic measures. Surgical cleanliness is more than ordinary cleanliness. 

Antiseptic precautions are employed for the purpose of securing for 
the wound and everything that is brought in contact with it an aseptic con- 
dition. The term antiseptic, used as a noun, should be restricted to agents 
which retard the growth of pathogenic germs, in contrast with the term 
germicide, which is applied to agents which destroy pathogenic microbes. 
A solution of corrosive sublimate, when introduced into a culture solution 
in the proportion of 1 to 300,000 will restrain the development of anthrax 
spores; but to insure the destruction of these spores a solution of 1 to 1000 
must be used. The mechanical removal of microbes from the field of opera- 
tion by shaving and washing with warm water and potash-soap should be as 



24 PRINCIPLES OF SURGERY. 

thorough as possible, but cannot be relied upon in securing asepsis. The sur- 
face must be disinfected with a reliable germicidal solution, either a 1-to- 
1000 solution of corrosive sublimate or a 4-per-cent. solution of carbolic acid. 
Accidental wounds must always be considered as infected wounds, and a 
faithful effort must be made to render them aseptic by exposing, if possible, 
the entire wounded surface to the direct action of one of these solutions, while 
the surface for a considerable distance around it is also disinfected. Ke- 
cently, a weak solution of the double cyanide of mercury and zinc has been 
recommended by Sir Joseph Lister as an antiseptic, and, from his experi- 
mental investigations and clinical experience, it appears that this substance 
possesses an advantage over carbolic acid, corrosive sublimate, and other anti- 
septics, as it exerts an inhibitory effect upon microbes which still may re- 
main in the wound or its immediate vicinity, which prevents them from 
multiplying in the tissues or in the dressing. At the present time many sur- 
geons depend almost exclusively on pure alcohol or a 50-per-cent. solution 
as an antiseptic for surface disinfection after thorough scrubbing with hot 
water and potash-soap. The finger-nails require special attention in hand- 
disinfection. Fuerbringer recommends the following procedure for the dis- 
infection of the hands: 1. Eemove all visible dirt from beneath and around 
the nails. 2. Brush the spaces beneath the nails with soap and hot water 
for a minute. 3. Wash for a minute in alcohol, and, before this evaporates, 
in the following solution: 4. Wash thoroughly for a minute in a solution 
containing 1 to 500 of corrosive sublimate or 3 per cent, of carbolic acid. 
On each side of the wound or field of operation a towel wrung out of an anti- 
septic solution is spread smoothly, in order that, during the operation, in- 
struments and sponges will not be contaminated by being brought in con- 
tact with non-aseptic clothing or surface. None but sterilized sponges are 
to be used, and, in the absence of such, pieces of aseptic gauze folded into 
convenient shape should be used as substitutes. The cheapest and most 
reliable method of disinfection of instruments is to boil them for five min- 
utes in a 1-per-cent. solution of carbonate of soda, and then place them upon 
an aseptic towel, ready for use. If these antiseptic precautions have been 
faithfully carried out, sterilized water can be used for irrigation during the 
operation, or the dry method of operating recently introduced into practice 
by Landerer can be followed in operating upon aseptic tissues or in the treat- 
ment of aseptic wounds. In the operative treatment of suppurative affec- 
tions, irrigation with a l-to-5000 solution of sublimate must be frequently 
resorted to during the operation, and, in the removal of tubercular products, 
irrigation with an aqueous solution of the tincture of iodine, made by add- 
ing enough of the tincture to sterilized water to impart to the solution a 
sherry color, should be used. 



CAREFUL HiEMOSTASIS. 25 



CAREFUL H^JMOSTASIS. 



The presence of a blood-clot between the surfaces of the wound is ob- 
jectionable for the following reasons: 1. It separates mechanically the sur- 
faces which it is intended to unite. 2. It serves as a culture-medium for 
microorganisms which, if in contact with living tissue, might remain harm- 
less. 3. It gives rise to tension, and consequently becomes productive of 
pain and an undue degree of reflex irritation. For years von Bergmann has 
insisted that careful arrest of haemorrhage is one of the most urgent and im- 
portant indications in the treatment of wounds, and his teachings merit the 
attention of every prudent surgeon. Bleeding-points should be tied with 
sterilized catgut or silk. A number of surgeons have discarded catgut, as it 
is more difficult to render it aseptic than silk. The latter can be readily 
sterilized by boiling. The haemorrhage that so often interferes with an ideal 
healing of the wound is the capillary or parenchymatous oozing, and this 
should always be carefully arrested before the wound is sutured. The fol- 
lowing measures should be resorted to in controlling this form of bleeding, 
and in the order named: 1. Position. 2. Surface compression. 3. Hot- 
water irrigation. 4. Antiseptic tampon. 

1. In wounds of the extremities capillary oozing is usually promptly 
arrested by holding the limb in a perpendicular position. In this position 
the intraarterial pressure is diminished and the return of venous blood 
favored, both of which are important elements in reducing the amount of 
blood in the capillary vessels. In order to produce the desired effect, this 
position should be maintained for fifteen to twenty 'minutes, and the limb 
should be kept elevated for at least six hours after the operation. 

2. Surface pressure with a flat sponge or a compress mechanically 
arrests the bleeding, and the capillary vessels, partly or completely emptied 
of blood, are placed in a more favorable condition for the formation of a 
thrombus. After an amputation, for instance, the sponge or compress is 
applied to the surface of the cut muscles and the flaps are laid over it and 
compression with two hands applied, with the limb in a perpendicular posi- 
tion before the elastic constrictor is removed. Compression, continued in 
this manner for ten or fifteen minutes, will usually be successful in com- 
pletely arresting parenchymatous bleeding. 

3. Irrigation with salt water (sodic chloride, 0.7 of 1 per cent.) at a 
temperature sufficiently high to coagulate the albumen on the surface of the 
wound seals mechanically the cut vessels, and, at the same time, produces a 
localized anaemia by contracting the terminal arterial branches. A tempera- 
ture of 120° F. will answer for this purpose. 

4. Styptics should never be employed in arresting bleeding from a re- 
cent wound. If the procedures mentioned fail in accomplishing the desired 



26 PRINCIPLES OF SURGERY. 

object, the wound should not be sutured until haemorrhage has been com- 
pletely checked by the use of the antiseptic tampon. The wound is packed 
with iodoform gauze, and the customary dressing is applied in such a man- 
ner as to exercise uniform gentle pressure. After twenty-four hours the 
dressing and tampon are removed, and the wound closed with sutures. In 
such cases secondary suturing is of great value in securing a speedy and satis- 
factory healing of the wound*. 

ACCURATE SUTURING. 

Brilliant operators are not always the best surgeons. The best results in 
surgery follow the one who is most painstaking in following out the minutest 
details. This assertion applies most forcibly in the treatment of wounds. 
The surgeon here occupies the position of handmaid to the vis medicatrix 
natures, and in the exercise of his duties must do all in his power to tax 
only to a minimum extent the regenerative resources of the wounded tissues. 
In the treatment of wounds it becomes his imperative duty not only to unite 
the surfaces of the wound accurately and neatly, but to unite, whenever it 
becomes necessary, tissues of the same anatomical structure and physiological 
function. Divided nerves, tendons, muscles, fascia, must be separately united 
with absorbable buried sutures before the wound is closed by the ordinary 
interrupted or continuous suture. When several nerves or tendons have been 
divided in the same wound, great care must be exercised to unite the ends 
of the same nerve or tendon. Accurate approximation of a deep wound is 
impossible without the buried suture. Several rows of these sutures may be 
required. Eeliable catgut should be preferred for the deep sutures, but if 
this material is not at hand fine silk can be used. The best materials for 
the ordinary interrupted sutures are silk or silk-worm gut. Separate sutures 
for the skin are usually required in order to approximate the superficial mar- 
gins of the wound accurately, and for this purpose horse-hair is the most 
desirable material. If the surgeon has reason to believe that the wound is 
aseptic, drainage should be dispensed with, because the manner of suturing, 
as just described, guards against the occurrence of "dead spaces." An ab- 
sorbent antiseptic compress, composed of a few layers of iodoform gauze and 
a thick layer of salicylated cotton, or sublimated moss or wood-wool, is the 
most appropriate dressing for such cases. The gauze bandage to retain this 
dressing is applied in such manner as to exercise uniform equable compres- 
sion: an important element in affording support to the injured vessels and 
in securing rest for the parts involved in the injury. Fixation of the wounded 
part by splints to secure rest and elevation to influence favorably the cir- 
culation are likewise important measures in aiding the process of repair by 
insuring 



UNION BY SECONDARY INTENTION. 27 



PHYSIOLOGICAL REST. 



In the after-treatment of a wound nothing is more important than to 
secure for the parts which have been mechanically united, as far as possible, 
physiological rest. The importance of rest in the prevention and treatment 
of inflammation has been prominently brought forward by Hilton, and his 
teachings have resulted in a great deal of good in the treatment of inflam- 
matory surgical affections. If one of the extremities is the seat of the wound, 
immobilization upon a splint or with a plaster-of-Paris dressing, in such a 
position as to relax the muscles involved in the wound, is of paramount im- 
portance. The injured part must be kept in a position which will favor a 
normal blood-supply and prevent passive hyperemia. A wound properly 
dressed should not be disturbed until union has taken place. If any one of 
the three most important indications for a change of dressing — pain, rise 
in temperature, and saturation of the dressing with wound-secretions — do 
not arise, the first dressing is allowed to remain for eight days to six weeks, 
according to the location, character, or size of the wound. In wounds of 
the gastro-intestinal canal physiological rest is secured by abstinence from 
food, and, if necessary, peristalsis is diminished by a few doses of opium. 
In wounds of the bladder distension of the organ is prevented by the intro- 
duction and retention of a catheter. In wounds of the brain or its envelopes 
rest is secured by exclusion of light and by enforcing quietude in the patient's 
room. 

UNION BY SECONDARY INTENTION. 

In an aseptic wound all the new material resulting from proliferation 
of the fixed tissue-cells is used in the process of repair, and the time for 
healing of the wound will depend on the anatomical structure of the part 
injured and the amount of material required to form a bridge of living tis- 
sue between the divided parts. As long as the wound heals without destruc- 
tion of any of the new tissue-elements by specific microbic causes, it is proper 
to speak of a union by primary intention, whether the healing is completed 
in three or four days or whether it is protracted for months until the ulti- 
mate object of wound treatment has been reached. From a pathological, 
and even from a practical, stand-point, it is not correct to include, under the 
head of healing by the second intention, aseptic wounds that, on account of 
want of proper approximation, or on account of loss of tissue, have of neces- 
sity to heal by granulation, with infected wounds in which the regenerative 
processes are disturbed by suppuration. In a suppurating wound the em- 
bryonal cells which are destined to become transformed into new tissue are 
exposed to the destructive action of pus-microbes and their toxins, their 
protoplasm is destroyed, and they become one of the histological sources of 
pus-corpuscles. The cells on the surface of the wound, being most distant 



28 PRINCIPLES OF SURGERY. 

from the vascular supply, possess the least power of resistance to the action 
of pus-microbes, and on this account, as well as from the greater number of. 
pus-microbes on the surface of the wound than in the deeper tissues, they 
are converted into pus-corpuscles. As long as suppuration remains active 
the superficial layer of granulation-cells is destroyed, and as soon as other 
embryonal cells take their place the process is repeated, and thus the healing 
of the wound is indefinitely delayed. 

When a favorable change takes place in the wound, either spontaneously 
or from the emploj'ment of antiseptic measures, suppuration is diminished, 
the granulations become firmer and more vascular, and cicatrization and epi- 
dermization now progress in a satisfactory manner. Such a favorable change 
in the condition of the wound can be readily explained after the use of such 
agents as are known to destroy the microbic cause of the suppuration when 
brought in contact with the wound. In such a case we would naturally 
expect that, with the removal, destruction, or rendering inert of the pus- 
microbes, the embryonal cells would remain attached to the point where they 
were produced, and would soon be converted into tissue resembling the 
matrix which produced them. Spontaneous cessation of suppuration, and 
with it the conversion of a surface covered with dead material into a healthy, 
granulating surface, would indicate either that the virulence of the pus- 
microbes had become attenuated, that the soil was no longer congenial for 
their multiplication, or finally that the resistance on the part of the tissues 
to their pathogenic action had become increased. That tissue-resistance has 
a potent influence in neutralizing and modifying the action of pathogenic 
microorganisms has been observed clinically and demonstrated experiment- 
ally. Suppurating wounds are graver affections, and are more difficult to 
manage in the aged and in badly-nourished persons, as well as in patients 
debilitated from all kinds of excesses and protracted diseases. A good cir- 
culation of the part is an important element in counteracting the cause of 
suppuration. A chronic varicose ulcer of the leg that suppurates freely, as 
long as the patient continues to use the limb, is often transformed into, a 
healthy granulation-surface after a few days of rest in bed with the affected 
limb in an elevated position. 

TREATMENT OF SUPPURATING WOUNDS, WITH SPECIAL REFERENCE 
TO HASTENING THE PROCESS OF REPAIR. 

In the treatment of an accidental wound, which always must be re- 
garded as a septic wound, or in the management of a wound where the anti- 
septic precautions have failed, no time should be lost in securing for the 
wound and its vicinity an aseptic condition by thorough disinfection. The 
surroundings of the wound are disinfected in the same manner as for an 
operation. The wound is exposed as thoroughly as possible to direct treat- 



SUTURING OF GRANULATING WOUNDS. 29 

ment by enlarging it over recesses otherwise inaccessible, after which it is 
thoroughly irrigated with peroxide of hydrogen, followed by a solution of 
sublimate (1 to 2000) or carbolic acid (2 1 / 2 to 5 per cent.). If the granula- 
tions are copious and flabby, they must be removed with Volkmann's sharp 
spoon, and after the bleeding has ceased a 12-per-cent. solution of chloride 
of zinc is applied; after a few minutes the surplus fluid is washed away by 
irrigation with the sublimate or carbolic solution. The wound is now dried, 
sutured, and drained. Drainage in these cases is a necessary evil, as the 
surgeon can never feel certain that he has succeeded in obtaining perfect 
asepsis. If the wound is extensive, or if pus has been burrowing in different 
directions along the deep tissues, as in cases of compound fracture where a 
thorough disinfection of every part of the wound, as already described, is 
impossible or impracticable, constant irrigation with a saturated solution of 
acetate of aluminum or Thiersch's solution should be instituted and con- 
tinued until the wound has been rendered aseptic. Acetate of aluminum is 
a reliable antiseptic, is non-toxic, and penetrates the tissues deeply. The 
treatment most appropriate for a recent aseptic wound is to be adopted as 
soon as suppuration has ceased and the general symptoms at the same time 
point to an aseptic condition. 

SUTURING OF GRANULATING WOUNDS. 

If union by primary intention has failed to take place, for any reason, 
in wounds which can be closed by suturing, a second attempt can be made 
to approximate the surfaces with sutures, with fair prospects of success as 
soon as the granulations are in an aseptic condition. Aseptic granulating 
surfaces when brought in contact unite rapidly, as vascular connections be- 
tween the new capillary loops are established in a remarkably short time, 
and the wound then heals in the same manner as after primary suturing. 
The cases best adapted for secondary suturing are those where suppuration 
has ceased, the granulations have become small and firm, — in short, wounds 
in which cicatrization has commenced. The technique in the treatment of 
such wounds is the same as in cases of aseptic recent wounds. The advan- 
tages of this method of dealing with wounds that have failed to unite are 
pronounced when the wound is deep and the margins can be coaptated with- 
out much tension. Buried sutures can be used for the same purpose and 
with the same benefit as in the treatment of recent wounds. Before the sur- 
faces are brought in contact with the sutures it is important to disinfect and 
dry the granulations thoroughly. As secondary suturing is applicable only 
in the treatment of such wounds where we have every reason to assume that 
an aseptic condition exists or can be secured by disinfection, the whole wound 
should be carefully closed and drainage must be dispensed with, in order to 



30 PRINCIPLES OF SURGERY. 

obtain rapid healing of the entire wound. It has been recently suggested 
by Hahn that in extensive defects of the skin a covering for the wound can 
be obtained by sliding of the skin, after undermining it for some distance, 
in a direction most suitable. That this procedure is applicable only under 
circumstances when the surgeon is sure of asepsis is to be taken for granted, 
as otherwise it might be followed by gangrene and still greater loss of tissue. 



CHAPTER II. 

Regeneration of Different Tissues. 

In connection with the subject of healing of wounds it is very im- 
portant for the student to familiarize himself with the vegetative capacity 
of the different tissues of the body in order to estimate with some degree 
of accuracy the part taken by each tissue in the reparative processes which 
take place after an injury or disease. No positive proof has yet oe&n- furnished 
that the leucocytes or any other of the cellular elements of the Hood take any 
active part in the restoration of lost parts. It does not appear to me reason- 
able or logical that such an indifferent cell as the leucocyte should ever be- 
come transformed directly into a fixed tissue-cell, and it is still more im- 
probable that it should be possessed with such a diverse vegetative capacity 
as to undergo a transition in one place into a connective-tissue cell, in an- 
other into bone, and still another into a muscle-fibre. It is much more 
rational to assume, in the repair of an injury and in the regeneration of a 
part destroyed by disease, that the universal law of legitimate succession of 
cells asserts itself, according to which the reparative process is initiated and 
completed by homologous cell-proliferation. 

In the following pages experimental and clinical proofs will be ad- 
vanced which will at least tend to establish the truth of this assertion. 

NON-VASCULAR TISSUE. 

The part taken by blood-vessels in regenerative processes is well shown 
in the healing of wounds of non-vascular tissue. Large wounds of the cornea 
and cartilage can only heal after a blood-supply has been established through 
new vessels from the nearest vascular district. Rapid vascularization of the 
non-vascular tissues is always observed when the wound has become infected. 

Cornea. — The normal cornea contains no blood-vessels, but vascular 
spaces, which form a system of channels for the circulation of the plasma- 
fluid. In 1863 Recklinghausen discovered in these spaces migrating cor- 
puscles, resembling in size and shape the white blood-corpuscles, which he 
regarded as offspring of the corneal corpuscles. Later, Cohnheim showed 
that these wandering cells were leucocytes which had escaped from the peri- 
corneal capillary vessels and had found their way into these channels. In 
traumatic keratitis these spaces become blocked with leucocytes, and they 
constitute largely the primary product of inflammatory exudation long be- 
fore the fixed cells of the cornea could have yielded such an amount of cel- 
lular elements. Strube and His studied experimentally the healing of 

(31) 



32 PRINCIPLES OF SURGERY. 

wounds of the cornea and traumatic keratitis. They injured the cornea of 
rabbits by cutting and cauterization. As the cornea is freely supplied with 
nerves, they observed as one of the earliest tissue-changes a reflex paretic 
dilatation of the marginal blood-vessels. The marginal hyperemia was fol- 
lowed by the formation of new blood-vessels in the direction of the seat of 
injury. The early opacity around the wound and the space between the 
wound and the advancing channels are caused by the presence of leucocytes 
in the vascular spaces; later, to proliferation of the corneal corpuscles. That 
leucocytes enter the plasma-canals when the cornea is irritated has been 
definitely settled by Cohnheim by one of his most ingenious experiments. 
He injected finely-divided carmine suspended in an acid, or precipitated 
aniline into the dorsal lymph-sacs of frogs, with the result that when he 
irritated the cornea, a few days later, leucocytes stained with the pigment- 
material appeared at the margin of the cornea where cell-migration was 
known to appear first. He found a rapid increase of corneal corpuscles in 
the animal subjected to experimentation; thus, in one instance, eighteen 
hours after the injury, he found, in spaces normally occupied by one cor- 
puscle, as many as twenty to thirty young cells closely packed together. 

D. J. Hamilton regards as the first change in an irritated cornea an 
increase of the plasma-current, which may destroy the endothelial lining of 
the canals, and according to this observer cell-migration into the corneal 
spaces occurs later. Unimpaired innervation of the cornea is an important 
factor in the prompt healing of wounds of this structure, as it is well known 
that in patients suffering from glaucoma, and in the aged, wounds of the 
cornea heal often in a very unsatisfactory manner. An aseptic wound of a 
normal cornea heals without opacity; the new corneal corpuscles, after they 
attain maturity, transmit light as perfectly as the cells from which they are 
produced. Imperfect restoration of tissue is to be expected when the regen- 
erative process is complicated by a suppurative inflammation with consid- 
erable destruction of tissue. Gussenbauer incised the cornea in rabbits half- 
way between the centre and its margin to the extent of half a line to a line, 
and found, in examining the specimens after twenty-four hours, that no 
union had taken place. The wound-surfaces at this time were glued together 
by an interposed substance. The surfaces of the wound were in close con- 
tact at a point corresponding to the middle portion of the cornea, and the 
gap widened toward each of its surfaces, so that the temporary cement-sub- 
stance represented two cones with their apices directed toward each other 
and the bases toward the surfaces. On staining the specimens with chloride 
of gold it was found that this substance contained cells which were most 
numerous toward the surfaces of the cornea. The corneal corpuscles on the 
cut surfaces were seen to be enlarged and presenting different stages of cell- 
division. Instead of round, the corpuscles were spindle-shaped, some con- 



XON- VASCULAR TISSUE. 



33 



taining one nucleus, others two nuclei; intercellular substance granular. 
In specimens eight days old the space between the cut surfaces was occupied 
almost exclusively by new corneal corpuscles, and the edges of the wound 
could no longer be clearly defined. During cicatrization of the wound the 
number of cells is diminished, while in form and size they resemble more 
and more the mature corneal corpuscles from which they were derived. 

In a non-penetrating incised wound of the cornea the gap is filled up 
after a few days with young cells derived from the cylindrical cells of the 
deepest layer of the corneal epithelia. 

If the wound has penetrated, the posterior third of the wound gapes 
toward the anterior chamber of the eye, and is first plugged with the prod- 
ucts of coagulation-necrosis, which is later replaced by epithelial cells from 
the membrana Descemeti (Fig. 19, C), while the anterior portion is occupied 
by epithelial cells the same as in the non-penetrating wounds. At the end 




Fig. 18.— Corneal Corpuscles in a State of Proliferation. A, old corneal corpuscles 
with one or two nuclei and young offshoots, B and C. (Senftleben.) 

of the first week the corneal corpuscles begin to proliferate, and the cells 
from this source gradually displace the epithelial cells and bring about the 
definitive healing of the wound. As wounds of the cornea are not sutured, 
the surgeon should aim to secure approximation by removing coagulated 
blood, if present, and by correcting any existing displacements by di- 
rect measures, and finally by applying a dressing which will exert uniform 
and equable elastic compression. Although the antiseptic treatment cannot 
be carried out with the same precision in the treatment of wounds of the 
cornea as in other localities, it is at least the duty of the surgeon to use only 
sterilized instruments and aseptic sponges, and to employ such mild anti- 
septic solutions as will at least exercise an inhibitory influence upon pathog- 
enic microorganisms that may be present in the w T ound or upon the surface 
of the eye. 

Cartilage. — Cartilage is in every sense of the word a non-vascular 
structure, as even the plasma-channels found in the cornea are absent here. 



34 



PRINCIPLES OF SURGERY 



Plasma-diffusion must take place between or through the cells. It is un- 
doubtedly on account of the limited provisions for nutritive supply that the 
vegetative capacity of this tissue is so exceedingly low. Normal cartilage 
when injured is unable to repair the defect. The process of healing of 
wounds of cartilage was first studied experimentally by Eedfern. In one 
experiment he found the wound almost unchanged after twenty-nine days. 
In one specimen, where the healing process had been completed, he found 
the defect repaired by connective tissue. The microscopical description of 
the healing process corresponded with that given by G-oodsir of inflammatory 




Fig. 19. — W T ound of Cornea. A- A', new corneal corpuscles; 
fibrin; C, epithelia from membrana Descemeti. 



B-A', temporary plug of 
{Ton Wi/ss.) 



processes in this structure. Along the margins of the wound the cartilage- 
cells multiply and the cement-substance is dissolved. Xo new cartilage-cells 
are produced, and the space is occupied by connective tissue. Vasculariza- 
tion toward the seat of injury from the marginal vessels of the perichon- 
drium takes place in the same manner as in the cornea. Eeitz traced the 
formation of connective tissue from the cartilage-cells in tracheotomy 
wounds in rabbits. He observed, after the cement-substance had become 
dissolved, that the cartilage-cells were transformed into spindle cells, and 
later into connective tissue. He found the gap between the divided carti- 
lage-ring filled with such cells a few days after the wound had been inflicted. 



VASCULAE TISSUE. 35 

and explains the discrepancy between the results he obtained and those 
described by Redfern on the ground of the close proximity of vascular sup- 
ply in his case and the remoteness of vessels from the wound studied by 
Bedfern, as the latter experimented on articular cartilage. G-ussenbauer 
studied the repair of cartilage wounds after incising subcutaneously costal 
cartilage. In wounds twenty-four hours old a triangular gap was found filled 
with fibrin and blood-corpuscles. No change was found at this time in the 
cartilage-cells and cement-substance. The cells of the perichondrium in- 
creased in volume and changed in form. Gussenbauer was unable to verify 
the observation made by Eeitz in wounds of trachea, that cartilage-cells are 
transformed into connective-tissue cells, and believes that the ammonia used 
by Eeitz to provoke croupous pneumonia, by its introduction into the bron- 
chial tubes through the tracheal wound, may have modified the result. He 
traces tissue-proliferation almost exclusively to the perichondrium, the 



Fig. 20.— Healing of Experimental Fracture of the Tibia of a Rabbit. A, young fibrous 
tissue. B, osteoid tissue forming by metaplasia from C, cartilage. X 250. 

cells of which were found in all stages of division and development, while 
only a few of the cartilage-cells presented evidences of segmentation. Dorner 
studied not only the manner of repair of simple incised wounds of cartilage, 
but also produced more complicated injuries, and invariably found that the 
perichondrium took a more active part in the process of healing than the 
cartilage-cells. Wounds of fibro- and reticulated cartilage heal in the same 
manner as wounds of hyaline cartilage. The histological changes observed 
by Redfern, Dorner, and G-ussenbauer during the repair of wounds of carti- 
lage are descriptive of the changes which attend chondritis. 

VASCULAR TISSUE. 

The healing of wounds of vascular tissue is accomplished more rapidly 
than of non-vascular tissue, as the primary wound-secretion, which is derived 
mostly from the wounded vessels, forms a temporary cement-substance which 
glues the parts together, — a condition which renders material assistance in 



36 PRINCIPLES OF SUEGEEY. 

maintaining coaptation, — while the direct blood-supply to the injured part 
cannot fail in increasing the vegetative capacity of the cells, and, lastly, the 
leucocytes present in the recent wound serve as food for the cells which are 
undergoing karyokinetic changes. As a rule, to which there are few ex- 
ceptions, it may be stated that the rapidity with which the healing process 
is completed is proportionate to the vascularity of the wounded part. For 
instance, wounds of the ringers heal much more rapidly than wounds of the 
arm or forearm, and wounds of the face more rapidly than wounds of the 
neck. Karyomitotic changes are first noticed in the nuclei of cells in close 
proximity to Mood-vessels. In studying the healing of wounds of vascular 
tissue, G-raser noticed that the connective-tissue cells a little distance from 
the surface of the wound were first to show evidences of karyokinetic changes; 
hence, it is apparent that the reparative process is initiated in cells most 
favorably located in reference to an abundant blood-supply, which corre- 
sponds to the location of capillary vessels which are undergoing dilatation 
prior to the formation of new blood-vessels. Eegeneration of tissue takes 
place most rapidly in parts where new blood-vessels are developed early, 
rapidly, and abundantly. The healing process is retarded or completely sus- 
pended when the capillary vessels, new and old, are seriously altered by in- 
flammation. 

Surface Epithelia. — Epithelial cells in a normal condition receive no 
direct blood-supply, but their relations to the subjacent vascular tissue are 
so intimate, and their proliferation in the healing of surface wounds and 
in the repair of defects caused by pathological conditions is so largely de- 
pendent on the development of new blood-vessels, that the study of their 
regeneration among the vascular tissues appears appropriate. In the con- 
sideration of this subject of epidermization, it has been shown that epithelial 
cells are derived exclusively from an epithelial matrix, either from the mar- 
gin of the wound or an islet of the epiblast buried among the granulations. 
Loeb has very recently advanced the theory that under certain conditions 
connective tissue can be produced from epithelial cells, but more experi- 
mental proof is required to disprove the law of the specific histological func- 
tion of cell growth and reproduction established by Eemak. Eegeneration 
of epithelial cells of the hypoblast takes place in a similar manner as has 
been described in epidermization of a wound of the cutaneous surface. Of 
special interest is the rapid regeneration of the gastro-intestinal mucous 
membrane. A recent gastric or intestinal ulcer presents elevated and swollen 
margins, and, as long as this condition remains, the healing process fails to 
become established until the swelling subsides, and paving of the granula- 
tions with epithelial cells is postponed until the surface of the ulcer is nearly 
on the same level with the surrounding border of the mucous membrane. 
Gritnni and Vassale made gastric fistula? in dogs for the purpose of studying 



VASCULAR TISSUE. 37 

directly, and during the life of the animals, the process of repair of wounds 
of the mucous membrane of the stomach. Through the fistulas they made 
superficial wounds of the inner surface of the organ, and from their observa- 
tions they satisfied themselves that healing takes place rapidly, and that re- 
generation of epithelial cells occurs in the peptic glands, where even as early 
as the third day the epithelial cells showed evidences of active proliferation. 
The new epithelial cells spread over the interglandular spaces, while a part 
of the glandular structure is lost during the process of healing. In traumatic 
defects where the glands have been excised with the mucous membrane the 
epithelial covering of the granulating surface is derived from the preformed 
epithelial cells of the mucous membrane bordering the wound. At a later 
stage new glands are formed by karyomitotic cellular changes after the nor- 
mal type of development of glands in the embryo. Even the youngest glands 
have an outlet, and the structure increases in depth by extension of mitotic 
changes in that direction. Pepsin-secreting cells are found only after the 
glands have attained nearly their normal depth. In one instance they were 
found only partly developed on the fortieth day. Connective-tissue prolifera- 
tion takes no essential part in the growth and development of the new glands. 
Visceral wounds of the stomach heal kindly and rapidly. Even gunshot 
wounds of this organ, when made with a small bullet, may heal without sur- 
gical interference, more especially if at the time the injury has been in- 
flicted the stomach is empty and all food is withheld for a few days. A strict 
diet is important in the treatment of wounds or ulcers of the stomach, as 
Leube has obtained excellent results from treatment of chronic ulcers of 
this organ by an exclusive milk diet. Griffini also made the observation that 
the traumatic defects which he produced in the interior of the stomach of 
dogs healed most rapidly when food was withheld entirely for a few days, and 
later on nothing but milk was allowed. From these observations and ex- 
periments it is evident that the young cells are unfavorably affected by the 
action of the gastric juice. 

Quincke has demonstrated experimentally, which has been a long- 
known and familiar clinical fact, that anaemia retards regeneration of the 
gastro-intestinal mucous membrane. In two dogs a gastric fistula was made, 
and through it a defect of the mucous lining was made of the same size in 
both animals. One of the animals was in perfect health, and healing was 
completed in eighteen days. The other dog was anaemic, and the healing 
process was prolonged thirty-one days. In the healing of an ulcer of the 
stomach or any portion of the intestinal canal the epithelial cells are first to 
take an active part in establishing a process of repair, the connective-tissue 
cells entering later upon their part of tissue-production. The healing process 
terminates most satisfactorily when only a small amount of connective tissue 
is formed and the epithelial covering is completed in a short time, as such a 



38 PRINCIPLES OF SURGERY. 

scar represents almost to perfection the normal tissue it has replaced. If 
a large quantity of granulation-tissue is produced by the connective tissue, 
and the formation of the epithelial covering is delayed for a long time, or is 
imperfectly accomplished, there is great danger of subsequent cicatricial 
contraction of the new tissue, producing a stricture. The best possible 
prophylactic means against the occurrence of strictures under such circum- 
stances are such dietetic and therapeutic measures as will secure for the 
ulcerated or wounded surface such favorable conditions as will expedite the 
paving of the surface with epithelial cells and limit the production of cic-r 
atricial tissue. 

TRANSPLANTATION OF SKIN. 

Epidermization of a large granulation surface is a slow process, even 
under the most favorable circumstances, and the resulting cicatrix is often 
large, gives rise to contraction, and not infrequently becomes the seat of 
keloid or ulcerative processes subsequently. Modern surgery offers means 
by which this tedious process can be materially shortened, and healing is 
accomplished by the formation of a more satisfactory scar. 

Reverdin's Method. — In 1854 F. H. Hamilton practiced successfully 
transplantation of skin in the treatment of chronic ulcers, and called the 
procedure anaplasty. In 1870 Eeverdin discovered that small, thin pieces 
of superficial skin, transplanted upon a healthy, granulating surface, formed, 
in a short time, organic connections with the granulations, and that epi- 
dermization proceeded independently from such transplanted islets of skin. 
Later, Schwenninger demonstrated, by his experiments, that hairs could 
similarly be transferred to a granulating surface. An open, granulating 
wound or ulcer can be covered over with epidermis in a short time by resort- 
ing to Eeverdin's method of transplantation of skin. The most essential 
condition for success is an aseptic condition of the granulations. In sup- 
purating wounds this method of treatment is not applicable until suppura- 
tion has ceased and the granulations are small and firm. The part from 
which the skin is to be taken, in preference the thigh or arm, should be 
shaved and disinfected. The only instruments required for cutting and 
transferring the skin is an ordinary sewing-needle fixed in a needle-holder, 
or, what is still better, a pair of haemostatic forceps and a sharp razor. With 
the needle the skin is transfixed, and with a razor a thin section the size 
of the circumference of a split pea is removed and at once transferred to 
the granulating surface with the needle in such a manner that the cut sur- 
face is brought accurately in contact with the granulations. As the de- 
tached portion of the skin always curls toward the raw surface at its mar- 
gins, it must be carefully flattened out with the point of one or two needles, 
care being taken to imbed it well among the granulations without causing 



TRANSPLANTATION OF SKIN. 39 

any bleeding. The grafts are planted in rows, commencing near the border 
and leaving small spaces between the separate grafts. Each row of grafts 
is then separately protected with a narrow strip of protective silk, and a 
thick, antiseptic compress is applied and retained by a bandage, which should 
exercise uniform gentle compression. The dressing should not be removed 
in less than a week. At this time the grafts will not only have become firmly 
attached to the subjacent surface, but each of them has become surrounded 
with a zone of new epithelial cells. As each graft now constitutes an inde- 
pendent centre of epithelial proliferation, the remaining portion of the gran- 
ulation surface soon becomes paved by new epithelial cells, and epidermiza- 
tion and cicatrization are rapidly completed. The results obtained by this 
method of treatment have not always been such as to satisfy the earlier ex- 
pectations. The new skin is but a poor substitute for the normal structure. 
Epidermization is hastened, and the results are better than after-healing 
without skin-grafting, but the ideal result, the formation of tissue resem- 
bling true skin, is not obtainable by this method of skin transplantation. 

Thiersch's Method. — If after an operation or injury it is found that a 
too extensive defect of the skin renders approximation by suturing impos- 
sible, the surgeon has it now in his power to supply the defect at once by 
taking large skin-grafts from another part of the body, or from another per- 
son, and planting them in the form of a mosaic upon the raw surface. This 
method of skin-grafting in the treatment of extensive superficial wounds. 
as after the extirpation of a lupus, or a surface epithelioma, was devised by 
Thiersch. Experience has shown that grafts of the whole thickness of the 
skin, and an inch square, if planted smoothly upon the raw surface and kept 
uninterruptedly in contact with the wound by an appropriate dressing, not 
only retain their vitality, but enter rapidly into organic connections with the 
part with which they have been brought into contact, and, at the same time. 
their anatomical and physiological properties are maintained to perfection. 
Thiersch found that after eighteen hours they were supplied with new blood- 
vessels, which could be successfully injected from the vessels of the part to 
which they had become adherent. This method of transplantation of skin 
is now extensively practiced in connection with plastic operations about the 
face. Eor such purposes the skin is taken from the region of the trochanters, 
as the skin here is almost or entirely devoid of hair. All bleeding from the 
wound to be covered with the grafts is carefully arrested by surface pressure 
before the grafts are planted, as it is necessary to secure accurate coaptation 
of the wound-surfaces in order to secure a favorable result. The modern 
method of performing rhinoplasty furnishes a good illustration of this 
method of skin transplantation. 

As a matter of course, success by this method of skin-transplantation 
can only be expected when the wound and grafts are aseptic, and the parts 



40 



PRINCIPLES OF SURGERY. 



are kept in this condition at least until vascularization of the grafts has taken 
place. After the grafts have been planted the treatment of the wound is the 
same as in Keverdin's method. During the after-treatment it is important 
to secure rest for the part, and to prevent, by appropriate means of fixation, 
even the slightest displacement of the grafts in any direction. A good plan 
is to apply a thin plaster-of-Paris bandage over the dressing. Schede has 
substituted Thiersch's for Keverdin's method in the treatment of granulating 
surfaces by skin-grafting, and the results have been very gratifying. The 




Fig. 21. — Rhinoplasty and Transplantation of Large Skin-grafts. A, A, skin-flaps 
from face turned inward and covered with large flap from forehead, C after C", and B 
after B'. Defects covered with mosaic of large skin-grafts from trochanteric region. 
(Thiersch.) 



granulating surface is transformed into a recent aseptic wound by removing 
the granulations with a sharp spoon. After all bleeding has ceased the wound 
is covered with large skin-grafts in the manner described. The skin obtained 
after this method of transplantation presents a normal appearance. I have 
repeatedly seen that, after excision of an epithelioma of the frontal or parietal 
region, a defect the size of the palm of the hand was healed completely in 
less than three weeks by using Thiersch's grafts. This method of skin- 
grafting must be a welcome resource to the oculists in the operative re- 



TRANSPLANTATION OF skin. 1 I 

moral of tuberculous lesions and malignant affections of the eyelids, as well 
as in the treatment of some forms of ectropion. 

Wolfe's Method. — Wolfe has obtained excellent results by covering 
defects of skin an inch or more in diameter with a single graft of skin de- 
prived of every vestige of subcutaneous fat. The removal of the graft must 
be done with the utmost care, to insure the entire thickness of the skin, 
and equal care is necessary not to transfer adipose tissue. If necessary, the 
graft may be fastened in place with a few fine catgut or horse-hair sutures. 

Hirschberg's Method. — Hirschberg has been successful in planting large 
skin-grafts without depriving them of the subcutaneous fat. In my own 
hands Wolfe's method has yielded better results. 

Transplantation of Mucous Membrane. — In the treatment of traumatic 
or ulcerative defects of accessible mucous membranes, it would seem that 
restoration of the defect by transplantation of grafts of mucous membrane, 
if found feasible, would be the ideal treatment. The first attempt at trans- 
plantation of mucous membrane was conducted by Czerny, in 1871. From 
1873 to 1888 it found practical application, but exclusively in ophthalmic 
surgery. Wolfler has recently shown that such a method of treatment is not 
only practicable, but has resorted to it successfully in the treatment of ob- 
stinate strictures of the urethra. After excision of the cicatrix at the seat of 
resection he sutured a circular graft of mucous membrane to each end of the 
resected urethra, and had the satisfaction to observe that the graft not only 
retained its vitality, but became adherent and constituted an essential part 
of the new portion of the urethra. Wolfe has also succeeded in transplanting 
the whole of the tissues of the conjunctiva of the rabbit on to that of man, 
in order to fill a defect caused by cicatricial contraction. Djatschenko, in 
1890, studied this subject experimentally, and elucidated the histological 
process. He experimented on dogs, taking mucous membrane from the 
mouth and inserting it in defects made by excising portions of the con- 
junctiva. He found complete union toward the ninth day, no real cicatricial 
tissue forming. He places great stress on rendering the graft bloodless and 
washing it in a warm 6-per-cent. solution of salt before it is implanted. While 
the graft should be freed of all fat-tissue, care should be taken not to deprive 
it of its submucous cellular tissue, as otherwise the conditions for the rees- 
tablishment of the circulation in the transplanted piece are less favorable. 
Another important rule laid down is to cut the graft sufficiently large to 
cover the entire defect, as the uncovered portion forms a scar. This method 
of dealing with large defects of mucous surfaces accessible to direct treat- 
ment holds out many inducements for future imitation. The difficulties in 
the way of equal uniform success in the transplantation of grafts of mucous 
membrane, as in skin-transplantation, are owed to the location of the seat 
of operation. In the former instance it must always be such as to preclude 



42 PRINCIPLES OF SURGEEY. 

the possibility of securing perfect asepsis, on the one hand, and the impos- 
sibility of applying an efficient protective dressing; at the same time, it is 
also more difficult to obtain the proper material for the grafting. 

CONNECTIVE TISSUE. 

The granulations seen upon a wound or ulcerating surface are formed 
almost exclusively by the transformation of mature connective tissue into 
embryonal tissue, the cellular elements of which they are composed being 
embryonal connective-tissue cells. This transition of mature into embryonal 
cells is accomplished by karyokinesis. As connective tissue is found almost 
in every part and organ of the body, it takes an active part in the repair of 
all wounds, and, when the more important tissues in the wound cannot be 
approximated for organic union to take place, its greater vegetative capacity 
enables it to produce a large amount of new material, which later forms a 
connecting bridge of cicatricial tissue. For instance, in a transverse wound 
of a muscle, where it is often difficult, if not impossible, to keep the divided 
ends sufficiently approximated for the wound to heal by the interposition 
of new muscle-cells, the gap is spanned by a band of connective tissue, which, 
if not completely, at least partially, restores the function of the muscle 
by furnishing it with two additional fixed points of attachment. Graser has 
shown that the first karyokinetic changes are seen in connective-tissue cells 
some distance from the surface of the wound, and that the new cells reach 
the surface with the new blood-vessels, where they constitute the granula- 
tion-tissue. In aseptic wounds, where cicatrization progresses rapidly, the 
embryonal connective-tissue cells, or granulation-ceils, are short lived, as 
they are rapidly transformed into mature connective tissue, which here con- 
stitutes the cicatrix. In suppurating wounds the superficial layer of em- 
bryonal cells is brought in contact with the pus-microbes and their toxins, 
which destroy the protoplasm of the cells, when they are transformed into 
pus-corpuscles, while those nearer the blood-vessels retain their vitality and 
capacity of undergoing cicatrization. 

BLOOD-VESSELS. 

Wounds of large blood-vessels, with few exceptions, require such meas- 
ures in their treatment which completely arrest the circulation and which 
aim at permanent obliteration of the lumen by the usual method of cell- 
proliferation and cicatrization. A wound of an artery, if accessible to direct 
treatment, should be treated by cutting the vessel completely across and 
applying a ligature to each end. A small wound of a large vein can be treated 
successfully, under favorable conditions, by closing it with a lateral ligature. 
With a tenaculum the margins of the wound are transfixed, and, bv making 



BLOOD-VESSELS. 



43 



slight traction, the vein-wall is raised, and around the base of the little cone 
thus formed a fine catgut ligature is applied. If the wound remains aseptic, 
the mural thrombosis at the seat of ligation is slight, and the closure of the 
wound is effected without obliteration of the lumen of the vessel. Larger 
vein wounds have been successfully treated by suturing with fine catgut. 
The sutures are inserted in the same manner as Lemberfs suture in closing 
a wound of the intestine. A wound of a blood-vessel usually terminates, 
spontaneously or through the intervention of art, in permanent interruption 
of the circulation by the formation of an intravascular cicatrix. For many 



Vasa vasorum 



Partly-formed connective 
tissue from erdotbelia. 




Proliferated 
connective 
^tissue in 
lumen. 



Fig. 22. — Microscopical Appearances of the Interior of Artery of Dog Forty-nine Days 
after Ligation. Transverse Section through Border of Artery. X 240. 



years it has been maintained that obliteration of a vessel after injury, dis- 
ease, or ligature resulted from what was termed "organization of the throm- 
bus." It was believed that the thrombus became vascular either from the 
lumen of the vessel or the vasa vasorum, and that the histological elements 
in the thrombus took an active part in the production of the intravascular 
cicatrix. Xumerous experimental investigations by different authors, un- 
dertaken for the purpose of demonstrating that in wounds of blood-vessels 
healing takes place in the same manner as in the wounds of other tissues, 
have shown that the blood-clot always occupies only a passive role, and, if 
present, is only in the way of a speedy, definitive closure, which invariably is 



44 



PRINCIPLES OP SURGERY. 



effected by proliferation from the fixed cells of the vessel-wall. Eliminating 
the thrombus as an active agent in the obliterating process, we can say that 
union between the tissues which are brought in contact by the ligature takes 
place by tissue-proliferation from the walls of the vessel itself. In the true 
sense of the word, direct or immediate union is as impossible here as in any 
other wound, and, like everywhere else, the intravascular cicatrix is formed 
from tissue derived from the tissue of the injured vessel-wall. In case the 
inner tunics are severed by the ligature, the lacerated surfaces are brought in 
contact with the adventitia, and repair takes place as in other tissues which 
are largely composed of connective tissue, the process extending from both 



Young 

connective 

tissue 

cells. 




Proliferation 
of connective 
tissue. 



Fig. 23. — Microscopical Appearances of the Interior of Vein of Dog Forty-nine Days after 
Ligation. Transverse Section of Part of Vein in Ligated Portion. X 240. 



sides of the ligature, where endothelia assist in the process of cicatrization. 
If, on the other hand, the continuity of the vessel is not destroyed by the 
ligature, and the intima is simply brought in contact without being ruptured, 
the new cells from the connective tissue perforate the endothelial lining, and 
the new elements of the latter join in the reparative process by being con- 
verted from their embryonal state into connective tissue. The histological 
changes in the interior of veins undergoing obliteration are the same as in 
arteries, the new material of which the cicatrix is composed being derived 
exclusively from the endothelial and connective-tissue cells. 

J. Collins Warren, who has done excellent work in studying experiment- 



BLOOD-VESSELS. 45 

ally the healing of arteries after ligature, maintain.- that lie has seen suffi- 
cient evidence in his specimens that the muscle-cells in the tunica media 
take an active part in the process of repair. The same author compares the 
process of healing in arteries to the formation of callus after fracture, and 
hence calls the intravascular material the internal and the extravascular the 
external callus. Ballance and Edmunds, in their classical work, "Ligation 
in 'Continuity," have given the profession the most reliable and exhaustive 
treatise on this subject. The numerous experiments of the author on ligation 
of arteries and veins have demonstrated, to his own satisfaction, that the 
most speedy obliteration of a vessel is obtained if the vessel is rendered blood- 
less by the application of two ligatures. The ligatures are applied with suffi- 
cient firmness to obliterate the lumen of the vessel icithout rupturing any 
of its coats. After ligation the walls of the vessel became thickened; so that, 
a few weeks after the ligatures had been applied, the vessel presented a 
spindle shape, tapering toward each side, a condition entirely due to the 
formation of new material: the external callus of Warren. The bloodless 




Fig. 24. — Femoral Artery of Dog Fifty Days after Double Ligation with Silk. Be- 
low, Transverse Section showing Bloodless Space Filled with Cicatricial Material. (Nat- 
ural size.) 

space between the ligatures is obliterated in a short time by cells which enter 
it from the vessel-wall. 

In the obliteration of veins and ligation of arteries in their continuity, 
the double ligature, including a bloodless space about 1 / 2 inch in length, 
places the tissues in the most favorable conditions for speedy, definitive 
closure by an intravascular cicatrix. When the vessel is exposed catgut 
should be used, but in the subcutaneous ligation of veins silk is preferable. 
Since the introduction of antiseptic surgery and the aseptic ligature, sec- 
ondary haemorrhage has become an exceedingly rare accident, and, when it 
does occur, it is in wounds where the antiseptic measures have failed. A 
vessel in an aseptic wound, tied with an aseptic ligature, becomes, in a few 
hours, the seat of a regenerative process which effectually guards against 
the possibility of haemorrhage, even if the mechanical obstruction caused 
by the ligature should be removed after a few days. The aseptic ligature, 
applied under strict antiseptic precautions, has been advantageous in other 
directions. The older surgeons always expected, after ligating an artery in 
its continuity, that the thrombus would extend on the proximal side to the 



46 



PRINCIPLES OF SURGERY 



nearest collateral branch, and, on this account, they were always anxions to 
secure a space of an inch or more between the ligature and the nearest large 
collateral branch, in order to prevent secondary haemorrhage. The aseptic 
ligature is never followed by such extensive thrombosis, and the intravas- 
cular cicatrix is often exceedingly narrow, — in fact, almost linear. The lim- 
ited thrombosis and the prompt formation of an intravascular cicatrix place 
the surgeon now in a position that he can ligate a large artery, close to a 
collateral branch or near a point of bifurcation, without a particle of fear of 
incurring secondary haemorrhage. In the ligation of veins the aseptic liga- 




Fig. 25.— Collateral Circulation Eight Months after Ligation of the Aorta in a Dog. 

(Luigl Porta.) 

ture has dispersed all fear of suppurative thrombophlebitis and pyaemia: com- 
plications which were formerly so much feared, even after insignificant op- 
erations on veins. In the repair of wounds union between the divided ends 
of blood-vessels is probably never effected. The vessel-ends are temporarily 
closed either by tying with a ligature or by the formation of a thrombus, the 
former being the case when vessels of some size have been divided, the latter 
being accomplished usually spontaneously in vessels which give rise to 
parenchymatous haemorrhage. In either instance the ends of the vessel are, 
later, permanently sealed by the formation of a cicatrix by proliferation of 
fixed tissue-cells, the endothelia, and connective-tissue cells. The inter- 
rupted circulation between the two sides of the wound is restored indirectly 



MUSCLES. 47 

through collateral branches, which are always new blood-vessels. The angio- 
blasts in the injured capillary vessels assume active tissue-proliferation within 
twenty-four hours after the injury has occurred, and through them, almost 
exclusively, the new blood-vessels are formed, in the shape of loops, which, 
coming, as they do, from both sides, establish the vascular connection be- 
tween the two surfaces of the wound. (See Fig. 25.) Many of these new 
blood-vessels disappear after the consummation of the reparative process, 
while others remain as permanent collateral vessels between the closed ends 
of the old blood-vessels permanently separated by the injury. 

MUSCLES. 

It is only quite recently that it has been ascertained that a divided mus- 
cle can unite, under favorable circumstances, by interposition of new mus- 
cular tissue between the divided ends. It was formerly believed that healing 
was always accomplished by the formation of connective tissue, and that the 
ends of the cut muscle remained permanently separated by a bridge of cic- 
atricial tissue. The theory that connective tissue can be transformed into 
muscular tissue is untenable, since Pflueger has demonstrated the minute 
structure of muscular fibre. Kolliker has shown that the fibrillar in the mus- 
cle-fibre constitute the real ground-substance. Eabl ascertained, by his em- 
bryological researches, that the muscular tissue is derived from a distinct 
portion of the mesoblast, and, consequently, proved that, at a very early 
period of embryonal life, an absolute difference takes place between mus- 
cular and connective tissue. Heterotopic muscular structures must, there- 
fore, be looked upon not as products of connective-tissue proliferation, but 
as a growth from a displaced embryonal matrix of muscular tissue. 

The vegetative capacity of muscle-cells, striped and unstriped, is quite 
limited, as compared with some of the other tissues; so that, if the ends of 
a muscle that has been cut transversely are separated for more than an inch, 
complete restoration of the continuity of the muscle is not attained, and the 
two ends are connected by a band of connective tissue. If, during the heal- 
ing of the wound, the cut surfaces of the muscle are kept in accurate contact, 
and even if a gap of half an inch exist between them, restoration ad integrum 
takes place by proliferation of the muscle-elements near the seat of injury. 

Non-striated Muscular Fibre. — Stilling and Pfitzner, as well as Busachi, 
have shown that unstriped muscular fibres multiply by indirect division of 
their nuclei, and, in the repair of wounds of this tissue, new fibres are pro- 
duced exclusively by this method. These authors studied the karyokinetic 
changes in the muscular fibres of the Triton tceniatus. They observed, after 
the division of the nucleus in the usual manner by karyokinesis, that as the 
new nuclei separated and approached the poles of the cell the protoplasm 



48 PRINCIPLES OF SURGERY. 

of the cell-body at the transverse axis became narrower, showing a well- 
marked constriction, which would indicate that subsequently cell-division 
occurred. Herczel witnessed similar changes in the hypertrophic muscular 
coat of the intestines on the proximal side of strictures. In defects caused 
by the injury, removal, or destruction of unstriped muscular fibres, regen- 
eration takes place only from the margins, while the centre at first is oc- 
cupied by connective tissue. The new muscular fibres are at first irregularly 
arranged, and it is only toward the completion of the healing process that 
the new tissue represents to perfection the mature muscular fibres. Klebs 
is of the opinion that the leucocytes serve as food for the cells which undergo 
karyokinetic changes. 

Striated Muscular Fibre. — 0. Weber, as early as 1854, claimed that in 
the healing of wounds new muscular fibres are produced, but, in accordance 
with the views which then prevailed, believed they were derived from con- 
nective tissue. Wittich saw, in hibernating frogs, new fibres which he be- 
lieved had developed from the cells of the internal perimysium. In 1865, 
after an examination of a genuine myoma striocellulare, Buhl expressed the 
opinion that new muscular fibres are produced from old fibres. In the same 
year Waldeyer discovered the muscle-cell sheath, and he regarded the cell 
inclosed by it as a derivative of the nucleus of the fibre, but, with Zenker 
and others, he still regarded the perimysium as the source of new muscular 
fibres. In 1868 E. Neumann made the observation that after section or 
laceration of a muscle the ends of the fibres became the seat of active tissue- 
changes, which resulted in the formation of what he termed muscle-buds. 
These muscle-buds were not only found at the ends of the fibres, but also 
on their sides; at first they were seen to be composed of numerous nuclei and 
protoplasm, while later they were transformed into striated fibres. The sar- 
colemma is such a delicate structure that new Cells which form within it 
readily find their way through it, and appear upon its outer surface in the 
shape of buds, as described by Neumann. 

Tizzoni has recently investigated the karyokinetic changes in the nuclei 
or sarcoblasts in the perimysium during the repair of muscle wounds. The 
first evidences of cell-proliferation were seen in the nuclei or myoblasts 
nearest the seat of injury, and proliferation took place in fibres which had 
undergone degeneration as well as in those which presented a striated ap- 
pearance. Leven found, during the first twenty-four hours after injury, an 
increase of nuclei of the sarcolemma-sheath. These new neuclei are arranged 
in the form of rows and heaps, and by mutual pressure are flattened. Many 
of these new elements present karyokinetic figures, and around them proto- 
plasm is deposited, and the new cells become spindle-shaped. The new cells 
increase in number from the third to the fourth day, so that at this time from 
five to six can be seen under one field. Klebs studied regeneration of mus- 



MUSCLES. 



49 



cle in young guinea-pigs after puncturing subcutaneously the gastrocnemius 
muscle. He came to the following conclusions: A portion of the muscular 
fibres die and shrink, and in this condition they can be stained more deeply 
with hematoxylin than the others. Such fibres are completely removed by 
absorption within the first four days. In the fibres which remain striated 
the fibrillas become plainer, and in them the regenerative process can be dis- 
tinctly seen. The nuclei increase in number, and are packed densely to- 
gether, but at this stage he was unable to detect any evidence of karyokinesis. 
During this stage Steudel was also unable to detect any appearances which 
indicated indirect cell-division. These young cells are called sarcoblasts by 
Klebs, and their transformation into muscle-fibres is effected by aggregation 




Fig. 26. — Muscular Fibres Near a Wound in a State of Proliferation. A, contused 
end of muscular fibre; B, muscular fibre retracted within sarcolemma, the latter ter- 
minating in a sharp point; C, old fibre degenerated into a colloid mass; D, young nuclei 
between and upon fibres; E, nuclei surrounded by cell-protoplasm; F, new cell, show- 
ing striations; G, new muscular fibre. (O. Weber.) 



around them of a very thin layer of protoplasm. The youngest cells are round, 
and the change into spindle form is gradual. The new cells are arranged in 
rows between the old muscular fibre (Fig. 26, between C7 and B). Some au- 
thors believe that the sarcoblasts unite end to end, and that the muscular 
fibre is formed in this manner. Kraske and Klebs maintained that muscular 
fibres result from a single cell by gradual elongation of the cell-body. In 
the regeneration of the muscular fibres of the heart after injury, Martinti and 
Bonome witnessed karyomitotic changes in the interior of the sheath of 
numerous fibres, while in others where degenerative changes had taken place 
no such changes could be seen. In wounds of the heart of old rats karyo- 
mitosis commences five to six days after the injury, and does not last longer 
than six to seven days, and results only in incomplete regeneration. In myo- 



50 TEIXCIPLES OF SURGERY. 

carditis the formation of new muscular fibres has been observed by Virchow, 
Boettcher, and Waldeyer. 

Muscle-suture. — In the treatment of recent wounds special pains should 
be taken to secure accurate approximation between the ends of divided mus- 
cles. For this purpose special means must be employed when large muscles 
have been divided transversely. In such cases the retraction which follows 
gives rise to great separation, which can only be overcome by suturing re- 
spective ends separately with buried animal sutures. Great care is necessary 
not to invert the margins, but to unite the cut surfaces throughout, using 
for this purpose, if necessary, as many as six sutures, which must include 
considerable tissue in order to prevent their tearing through. The muscle- 
ends should be secured with a mattress-suture of chromicized catgut as shown 
in Fig. 27, and the edges carefully coaptated with three or more points of 




Fig. 27. — Muscle-suture. 

suture of the same material. In muscles supplied with a well-marked sheath 
this should be sutured separately. In the after-treatment it is necessary to 
place the limb in such a position that will relax the sutured muscles, and to 
secure immobility of the limb in this position by a proper mechanical sup- 
port, which should not be removed until the healing process is completed, 
m order to prevent subsequent diastasis between the sutured ends. "When it 
is desirable to elongate a contracted muscle in the correction of deformities, 
as in the treatment of torticollis, the contracted muscle should be exposed 
by incision, and after section a suture a distance is applied. A number of 
heavv catgut sutures will answer an excellent purpose, as they will maintain 
fixation of the separated ends in a desirable position, and will furnish an 
admirable scaffolding for the new connective-tissue cells, which, later on, 
are transformed into a tendon which permanently connects the retracted 
ends of the divided muscle. 



MUSCLES, 



51 



Tenorrhaphy. — The operation of suturing a tendon is called tenor- 
rhaphy. The histological processes in the regeneration of a tendon are the 
same as in the repair of connective tissue. Tendons are composed of com- 
pact connective tissue surrounded by a delicate membrane: the tendon- 






Fig. 28. — Tenorrhaphy, a, mattress-suture; b, c, after Wolfler; d, e, paratendinous 
suture, after Hueter. (Esmarch.) 

sheath. In injuries of tendons the fibroblasts furnish the new material,, 
which is interposed between the cut or torn ends and which restores the con- 
tinuity of the tendon. The process of repair is instituted near the tendon- 
ends and shows itself in the splitting up of the fibrils. The new material acts 





III 

L_ :: 's. 




Fig. 29.— Tendoplasty. a, after Madelung; b, after Tillaux; c, after Hueter; 
(Z, after Gluck. (Esmarch.) 

first the part of a cement-substance, but in the course of two or three weeks 
is transformed into new connective tissue. In open wounds, complicated 
by injury to tendons, the careful surgeon never neglects to place the tendon- 
ends in the most favorable conditions for speedy and satisfactory repair by 



52 



PRINCIPLES OF SURGERY. 



resorting to primary tendon-suture. If a number of tendons have been in- 
jured at the same time, it is often difficult to identify the ends which belong 
together and much time is often consumed, and a great deal of care must be 
exercised in finding and suturing the respective ends. If the proximal end 
has retracted into the sheath beyond easy reach it is better to lay the sheath 
open than to make repeated fruitless attempts to grasp the tendon. The best 
suturing material is chromicized catgut. The technique of tenorrhaphy is 
well shown in Fig. 28. 

The surgeon is often called upon to restore the continuity of a tendon 




Fig. 30.— Secondary Suturing of Extensor Tendons of Fingers by the 
suture a distance. (E. J. Senn.) 



in cases in which primary tendon-suture was neglected or in which it failed, 
and then resorts to secondary tenorrhaphy, which is performed in the same 
manner as primary tendon-suture, after the tendon-ends have been exposed 
and vivified. 

Tendoplasty. — In cases in which the loss of substance in tendon injuries 
renders approximation of the tendon-ends impossible, and in many cases of 
open tenotomies for contractured tendons, restoration of the continuity of 
the tendon can only be secured by a plastic operation, which in this instance 



MUSCLES. 



53 



is called tendoplasty. A number of valuable procedures are shown in Fig. 
29. 

Gluck interposes between the ends of the tendon a braided bundle of 
catgut, which acts as a temporary bridge-work for the fibroblasts and which 
is replaced, in the course of time, by permanent tissue. E. J. Senn employed 
this method of suturing a distance with great success in a case of extensive 




IlillllliiSIIIIIti!' 
Fig. 31. — Tendon-elongations. 

loss of tendon-tissue involving all of the extensor tendons of the fingers of 
one hand. The degree of separation of the tendon-ends and technique of 
operation are shown in Fig. 30. The patient recovered full use of the ex- 
tensor tendons in the course of two months. 

An exceedingly valuable method of effecting elongation of a contract- 
ured tendon was devised by Anderson. It consists in splitting the tendon 
longitudinally and cutting each half on opposite sides sufficiently far apart 



54 PRINCIPLES OF SURGERY. 

so that the necessary degree of elongation can be secured by suturing to- 
gether, end to end or laterally, the long ends. (Fig. 31.) In uniting a large 
tendon, either by simple suturing or by a plastic operation, it is important 
to suture the sheath separately; or, if this is absent, to make a new sheath 
of connective tissue with which the tendon should be covered. Immobiliza- 
tion of the limb must be continued until the process of repair is completed, 
which will require from three to six weeks. 

BONE. 

The granulation material by which the fractured bone unites is called 
callus. According to the location of this material around, within, or between 
the fragments, we speak of an external, internal, or intermediate callus. 
The external, or provisional, callus is abundant, as a rule, where the broken 
bone is surrounded by a thick cushion of soft parts, and when the fragments 
are not well immobilized. It forms early and disappears gradually after the 
fracture has united. The internal, or medullary, callus, which takes the 
place of the medullary tissue in fractures of the shaft of the long bones, 
serves a useful purpose as a means of fixation of the fragments, and is also 
removed in the course of time after union has taken place, and with its dis- 
appearance the medullary cavity is restored. The intermediate, or definitive, 
callus is the material interposed between the broken surfaces, and which is 
transformed into permanent tissue. Callus is the product of cell-prolifera- 
tion of those tissue-elements which are directly concerned in the growth and 
development of bone. 

Duhamel de Monceau attributed to the periosteum and endosteum the 
function of producing callus. Haller and his prosector, Detlef, believed that 
the periosteum takes no part in the regeneration of bone, but that callus is 
derived from the fractured ends of the bone, more especially the myeloid tis- 
sue. Dupuytren maintained that the periosteum and the paraperiosteal con- 
nective tissue were bone-producing tissues. Cruveilhier claimed that the 
lacerated soft tissues around the fractured bone-ends, the periosteum, con- 
nective tissue, muscles, tendons, etc., furnished the material for the callus. 

Flourens claimed that the periosteum alone could produce new bone. 
Rokitansky asserted that callus is developed directly from bone and its con- 
nective tissue, including the periosteum. From his own experimental work, 
E. Heine came to the conclusion that regeneration of bone takes place from 
connective tissue in and around bone and the periosteum. According to 
Virchow, callus is produced from connective, tissue outside of the bone, as 
well as from the medullary tissue. Hofmokl considered as sources of callous 
formation the periosteum, bone, and marrow. Gegenbauer takes the ground 
that bone is produced directly from connective tissue. He asserts that 



BONE. 



55 



Sharpey's fibres, if traced carefully, can be seen springing from a bony point 
between the Haversian canals, from which point they radiate toward both 
sides into the lamellar systems. The fibres form net-works, and at points 
of intersection bone-cells are produced, and a deposit of lamellae takes place 
around the connective-tissue fibres. 

It is now generally conceded that the provisional callus is the product 
of tissue-proliferation from the periosteum, while the definitive, or perma- 
nent, callus is produced directly from the medullary tissue. The provisional 



M 




Fig. 32.— Section through Callus Fifty-two Hours after Fracture of Ulna from 
Rabbit. Beginning Formation of Osteoid Tissue. A, cortical portion of bone; B, osteoid 
tissue; C, beginning of formation of a lamella, surrounded by osteoblasts; D, perios- 
teum. (Hartnack, obj. 8.) (Bajardi.) 

callus is Nature's splint, its only object being to immobilize the parts until 
the definitive callus firmly and permanently unites the fragments. The 
temporary callus is an accidental product, and appears earliest and most 
copiously where the paraperiosteal tissues are most abundant and motion be- 
tween the fragments greatest; the intermediate or permanent callus is pro- 
duced later, and is transformed into permanent tissue. Ollief and Bucholtz, 
in their experiments on transplantation of periosteum, found that the trans- 
planted tissue first produced cartilage, which later was transformed into 



56 



PRINCIPLES OF SUEGEEY. 



bone; but they also ascertained that snch bone disappeared again unless it 
formed in a place where bone normally exists. Cohnheim and Maas came to 
the same conclusion from their experiments on intravenous transplantation 
of periosteal graft. It is possible that special cells (Mastzellen) are the active 
agents in the removal of tissue in places where it has no physiological exist- 
ence. Macewen has maintained for years that bone grows only from bone, 
and the results obtained by applying this principle in practice speaks strongly 
in favor of this supposition. That medullary tissue alone can produce bone 
has been experimentally demonstrated by Bruns. The osteoblasts from 




Fig. 33.— Transverse Section through Callus of Tibia of Rabbit Forty Days after 
Fracture, with External Resorption. P, periosteum, much thickened; R, giant ce^ls or 
osteoclasts; O, blood-vessels; M, medullary resorption-spaces; K, compact portion of 
bone. (Maas.) 

which bone-production alone can take place are found in the periosteum, 
more especially its inner layer, the cambium, and in the interior of bone. 
Kegeneration of bone from these cells takes place in two ways: either the 
cells are transformed into an osteoid tissue or they are first changed into 
cartilage-cells, and the latter at a later stage undergo ossification. The osteo- 
blasts in the periosteum, and, to a lesser extent, those in the central medul- 
lary cavity, produce bone by this indirect method, while in other places 
ossification is effected in a more direct way by the osteoblasts being trans- 
formed into an osteoid substance. 

In the normal regeneration of bone cartilage plays an important part. 



BONE. 57 

As the bone-cells disappear, or at least lose their nuclei where cartilage- 
cells form, it is probable that the cartilage-cells represent structures inter- 
mediate between osteoblasts and bone-cells. Cartilage is abundant where 
union is retarded, and especially in cases of pseudarthrosis. During ossifica- 
tion the hyaline cement-substance between the cartilage-cells is dissolved, 
and the space gives way to lamellae, while the cells are transformed into 
bone-cells. According to Krafft, multiplication of the bone-producing cells 
of the periosteum can be seen twenty to thirty hours after fracture, in the 
shape of karyokinetic figures in the nuclei of the cells, while somewhat later 
the same figures are to be seen in the endothelia lining the blood-vessels. 
The new cartilage-cells also multiply by karyokinesis. Like in the healing 
of wounds in soft parts, the cells on the surface of the fracture take no part 
in the process of regeneration, as their proliferative capacity has been de- 
stroyed by the trauma as well as the sudden diminution of the vascular sup- 
ply. Osteoporosis at the seat of regeneration is always present, and results 
from the action of another kind of cells discovered by Kolliker, — the osteo- 
clasts. Bobin described them as my elo plaques. They are found in How- 
ship's lacunae, where resorption takes place. 

The osteoclasts appear to be nothing else but myeloid cells which have 
lost their bone-producing function; they are, in reality, hyperplastic osteo- 
blasts. Absorption of bone takes place because these cells do not produce 
bone. There is no reason to believe that these cells are altered bone-cells, 
as no intermediate forms have been found. Ziegler does not assign much 
influence to these cells in the resorption of bone. Wegner has shown that 
in pathological processes in bone where resorption takes place they are 
arranged along the sides of blood-vessels, and on this account he believed 
they were derived from the vessel-wall. Klebs is of the opinion that the 
osteoclasts may secrete a chemical substance which decalcifies the bone. 
Eesorption of superfluous callus is accomplished undoubtedly by the action 
of osteoclasts, an exceedingly useful function, as by it form and strength of 
the broken bone are restored. 

According to Meyer, the architectural structure of the spongiosa, after 
the healing of a fracture, adapts itself to the new conditions, so that the new 
traction and pressure-curves are arranged in such a manner as will resist the 
greatest degree of force. This capacity of adaptation is present to a very 
high degree in bone. 

Abnormal and Defective Callus. — Callus may be formed in excess of 
local requirements after a fracture, and yet no union take place. The osteo- 
blasts respond promptly to the stimulus created by the trauma, karyokinetic 
changes occur early, new cells are formed with great rapidity, and a large 
mass of new material is deposited at the seat of fracture, but bony consolida- 
tion does not occur, because the new tissue does not undergo ossification. 



58 PRINCIPLES OF SURGERY. 

The normal development of cells is arrested at an early stage, and the chem- 
ical processes upon which ossification depends are delayed or fail to appear 
altogether. Prompt bony union does not only imply that the osteoblasts at 
the seat of fracture should undergo karyokinetic changes and multiply, but 
that the new tissue must be placed under the influence of favorable chemical 
conditions which will enable it to be transformed into bone. 

A few years ago B. von Langenbeck reported two cases of fracture of 
the femur where he resorted to amputation of the thigh under the belief 
that the luxuriant callus, which formed in each case at the seat of fracture, 
was a sarcoma. Microscopical examination in both instances showed that the 
swelling was composed of cells which are found in callus at an early stage 
of its formation, without any evidences of ossification of the new material. 
The causes of delayed ossification are not known, but, as in a number of 
instances of profuse callous formation and delayed union a vigorous anti- 









#|fc» 



Fig. 34. — Osteoclasts Absorbing Bone. A, osteoclasts. B, osteoblasts. 

syphilitic course of treatment produced favorable results, it appears that 
the virus of syphilis may at least be one of them. We know that in gummata 
the same conditions prevail in the persistence of tissue in its embryonal state 
for an indefinite period of time, or until the syphilitic virus has been re- 
moved or neutralized by proper antisyphilitic treatment. 

In cases where no such cause for the delay of the transition of callus into 
bone can be surmised, the internal administration of minute doses of phos- 
phorus should be tried. Kassowitz produced osteoporosis in animals ex- 
perimentally by large doses of phosphorus, while minute doses produced an 
opposite effect. He recommended the remedy in small doses in the treat- 
ment of rickets, and since then it has been extensively used in the treatment 
of this disease, and with the best results. The action of this drug undoubt- 
edly would produce a favorable effect upon the osteoid material, in hastening 
its transition from the embryonal into a mature state. 



HONE. 0\) 

The amount of callus thrown out in every instance depends on: 1. The 
general condition of the patient. 2. The location and structure of the fract- 
ured bone. 3. The amount of local injur}*. 4. The degree of displacement. 
5. The perfection of immobilization. 

As a rule, a minimum amount of callus is produced when the patient 
is suffering from any wasting or acute febrile affection or is the victim of 
any so-called constitutional diseases; when the broken bone is very com- 
pact and located near the surface of the body; when the injury was slight, 
with little or no displacement, and when during treatment the broken ends 
have been kept at rest and in constant and in uninterrupted coaptation. 

Opposite conditions are followed by an exuberant production of callus. 
The influence exercised by paraperiosteal tissues in determining the amount 
of callus is well illustrated in fractures of the tibia and ulna; where the bone 
is subcutaneous little or no callus is found, while in places where it is deeply 
covered by muscular and aponeurotic tissue the amount of callus is great, — 
in some instances so great that it tills the entire interosseous space, forming a 
bridge of bone across it, permanently cementing the fibula or radius, as the 
case may be, to the broken bone. 

To obtain bony consolidation after a fracture certain well-recognized 
conditions are necessary: 1. A sufficient blood-supply to the part. 2. Un- 
impaired innervation of the part. 3. Placing and maintaining the frag- 
ments in contact, or at least in such close proximity that the callus thrown 
out from both extremities can meet and establish a bony bridge between. 
Injury of any principal vessel or nerve of a limb, as a complication of any 
fracture, does not only endanger the integrity of the limb, but may consti- 
tute an important element in the production of non-union. 

Injury of the nutrient vessels of long bones has no influence in prevent- 
ing the formation of callus, claimed by several writers, inasmuch as the com- 
bined statistics from the practice of different surgeons do not sustain this 
assertion. An excessive supply of blood in the part — either from an undue 
afflux of blood, the consequence of an excessive irritation about the seat of 
fracture, or from obstruction to the venous return — frequently affects callous 
formation in a detrimental manner. These conditions often interfere with 
the normal reparative process, the histological elements which are intended 
to furnish the callus not undergoing the typical embryonal tissue-transforma- 
tion. 

The following are the principal causes which have been enumerated as 
giving rise to false joints: — 

Rachitis. G „t.ji;« 

, Q , , Syphilis. 

General \ w?- !i- Acute febrile affections. 

\\ asting diseases. -d 

-p, , e , , ... Pregnancy. 
I Prolonged Jactation. e 



60 



PRINCIPLES OF SURGERY. 



f Interposition of soft tissue between fracture. 
I Separation of fragments. 
I Imperfect immobilization. 
Local -{ Imperfect circulation from concomitant swelling, too tight 
dressing, or position of limb. 
I Obliquity of fracture. 
L Complication of fracture. 

I have not enumerated old age as a cause for delayed or non-union. 
Statistics show that these accidents are found almost exclusively in young 
people at the age of 20 to 35 years. With the exception of joint fractures, 





Fig. 35. Fig. 36. 

Fig. 35.— Old Method of Bone-suture. 

Fig. 36. — Improved Bone-suture. Transverse Fracture, Wire Suture including 
Entire Thickness of Both Fragments. 

fractures unite promptly and in a short time in the aged. Senile osteoporosis 
may be considered a favorable condition for a callous formation. 

A great diversity of opinion prevails among surgeons in regard to the 
influence of general conditions on the production of callus. Some claim 
that non-union is almost invariably due to general causes. I recollect very 
well the remark of the late Professor von Nussbaum on this subject. In a 
lecture he claimed that nearly all, if not all, fractures that fail to unite by 





Fig. 37. Fig. 38. 

Fig. 37. — Wire Drawn through the Perforation. 
Fig. 38.— Wire Cut in the Centre and Each Half Twisted Separately. 

bone occur in patients suffering from some constitutional taint, more espe- 
cially syphilis. He referred to several cases where no attempt at union took 
place under the most favorable local conditions, and where a course of mer- 
curial inunction was promptly followed by bony consolidation. 

Defective callous formation will necessarily follow a fracture if the 
osteoblasts fail to enter upon an active process of cell-proliferation. These 
are the cases where the surgeon resorts to local measures which are intended 



HONK. 



61 



to stimulate the cells to increased activity. Fractures of the lower extremi- 
ties which have failed to unite as long as the patient is kept in bed often 
unite promptly after he is allowed to walk around on crutches, the favorable 
change being brought about by an increased blood-supply to the seat of 
fracture. 

Dumreicher suggested that the local blood-supply could be increased 
by applying a compress and bandage above and below the seat of fracture, 
while Helferich more recently, and with the same object in view, advised 




Fig. 39. — Serin's Hollow Perforated Intraosseous Splint. 

moderate constriction with an elastic bandage applied in such a manner as 
not to interfere with the arterial circulation. Eubbing of the fragments 
forcibly against each other is an old method of treating delayed union, and 
has often been sufficient to rouse the dormant osteoblasts into active cell- 
proliferation. The distinguished Brainard made the treatment of delayed 
union a special study during many years of his useful life, and devised a new 
method of treatment,— the subcutaneous drilling of the ends of the frag- 
ments, — which has been extensively practiced and has yielded most excel- 






Fig. 40. Fig. 41. Fig. 42. 

Fig. 40. — Circular Bone Ferrule for Humerus or Femur Made of an Ox-femur. 
Fig. 41.— Triangular Bone Ferrule for Tibia Made of an Ox-tibia. 
Fig. 42.— Wide Perforated Bone Ferrule. 

lent results. The drilling of the ends of the broken bone has a most de- 
cided effect in stimulating the sluggish reparative process, as it produces 
osteoporosis and increases the vascularity of the parts, both of these condi- 
tions being well calculated to increase the local nutrition. Dieffenbach went 
one step farther, and advised the use of ivory nails, which were allowed 
to remain until they became loose and dropped out. The term non-union 
is a relative one, as in some fractures this condition may have been reached 
in three to four months, while others may unite after a year. 



62 



PRINCIPLES OF SURGERY. 



In a fracture of the femur, in a healthy man who came under the au- 
thors observation, that had not united a year after the accident, bony con- 
solidation took place after this time without any operative interference. In 
another case bony union did not occur until nearly two years after the fract- 
ure had taken place. When a pseudoarthrosis has once become established. 





Fig. 43. Fig 

Fig. 43.— Oblique Fracture of Femur United by Bone Ferrule 
Fig. 44. — Transverse Fracture of Humerus Immobilized by 

Bone Ferrule. 



a Wide Perforated 



all measures which have been found useful in the treatment of delayed 
union are useless, and the only rational treatment in such cases consists in 
transforming the old fracture into a recent one. The ends of the fragments 
are exposed, the interposed ligamentous structures — muscles or tendons — or 
false joint excised, and the ends vivified in such a manner as to furnish large 
surfaces for apposition. The bone should never be cut transversely, but 



BONE. 



03 



always obliquely, or, what is still better, Yolkmann's step-operation should 
be done wherever the existing conditions make this possible. Direct fixa- 
tion of the fragments with aseptic bone or ivory nails should always be prac- 
ticed, as by this expedient we are able to secure greater immobility between 
the fragments, and at the same time the perforations and the presence of 
the foreign bodies cannot fail in imparting an additional stimulus to the 
tissues which will expedite the process of repair. 

The silver-wire suture has been used for a long time to secure fixation 
of the fragments in recent fractures and in cases of non-union. 




Fig. 45. — Serin's Splint Apparatus Applied; Pad Making Pressure over 
Trochanter in the Direction of Neck of Femur. 



In uniting oblique fragments Willed method of suturing, shown in 
Figs. 37 and 38, is to be preferred. Bircher has employed cylinders of ivory, 
which he introduced into the medullary cavity as a means of fixation. The 
writer has substituted, for the solid ivor}^, hollow perforated intraosseous 
splints to meet the same indications. As another means of direct fixation, 
the author has devised and successfully employed bone ferrules in a number 
of cases. The shape, size, and application of these ferrules are well shown 
in the accompanying illustrations. (Figs. 39 to 42.) 

The frequency with which non-union is met with after intracapsular 
fracture of the neck of the femur has almost bv universal consent been at- 



64 



PRINCIPLES OF SURGERY. 



tributed to defective callous formation. It has been claimed that in such a 
fracture, occurring as it usually does in persons advanced in life, callous 
production is always defective, and, as the upper fragment is but scantily 
supplied with blood-vessels, it was asserted that it was not in a condition 
to take an active part in the reparative process. The author made numerous 
experiments on animals, fracturing the neck of the femur within the limits 
of the capsular ligament, and as long as the fracture was treated in the cus- 
tomary way bony union was never attained. He then resorted to direct means 
of fixation by transfixing both fragments with an absorbable nail, and with 
this treatment succeeded in obtaining bony union in the majority of cases. 
Since that time he has treated fractures of the neck of the femur by im- 
mediate reduction and permanent fixation with a plaster-of-Paris splint, with 
pressure over the trochanter major in the direction of the axis of the neck 
of the femur with a compress and set-screw, the latter passing through a 




Fig. 46. — Semi's Splint Apparatus for Treating Fracture of Neck of Femur. 



splint which is incorporated in the plaster-of-Paris dressing. With this treat- 
ment he has obtained bony union in a number of instances where all the 
signs and symptoms pointed to a fracture within the capsular ligament. 

It is a well-established clinical fact that in the aged other fractures 
unite readily, and pseudarthrosis is exceedingly uncommon, excepting after 
this fracture; and the writer is satisfied that this undesirable result occurs 
more in consequence of improper treatment than defective callous pro- 
duction. If the fragments can be brought in accurate apposition soon 
after the accident has occurred, and coaptation can be maintained uninter- 
ruptedly for three months by an appropriate dressing, bony union can be 
secured, not only in exceptional, but in the majority of, cases. In the treat- 
ment of fractures, as in the treatment of wounds of the soft parts, accurate 
coaptation and effective fixation should be aimed at, so as to place the parts 
in the most favorable condition to unite by the smallest possible amount of 
new material. 



GLANDS. 65 



GLANDS. 



Testicle. — Griffini studied regeneration of testicle-substance in frogs, 
dogs, chickens, and guinea-pigs. He excised a wedge-shaped piece under 
strict antiseptic precautions, and killed the animals in from three to seventy- 
five days. Examination of the specimens showed that an increase of tubuli 
seminiferi had invariably taken place. They appeared to have originated as 
blind pouches from preexisting tubules. 

Liver. — Tizzoni has also observed, in his experiments on dogs, produc- 
tion of new gland-tissue during the healing of wounds of the liver and after 
partial excision of this organ. 

Ponfick studied regeneration of liver-tissue in dogs and rabbits, remov- 
ing two-thirds to three-fourths of the organ. The animals were killed in 
from two to fifty days. Karyokinetic changes were seen as early as the 
second day. Following regeneration of the parenchyma, vascularization of 
the new tissue set in promptly. Regeneration of the biliary ducts was 
studied by injecting indigo-carmin into the circulation. The animals were 
killed in from one and one-half to two hours, and even at this early period 
after operation distinct evidences of a beginning process of repair were de- 
tected. There are now a number of cures recorded in which extensive losses 
of liver-tissue caused by injury or operation in the human were repaired 
without any functional disturbances following. 

Spleen. — The same author studied experimentally regeneration of the 
spleen-tissue, and found that this occurred after partial and complete ex- 
tirpation, the new tissue being made up of elements in connection with 
blood-vessels of the adjacent peritoneum. After complete extirpation of 
the organ the new spleens appear as nodules of a brownish color, which are 
attached to the vessels of the peritoneum, and develop around new buds of 
these vessels. The beginning of such a minute spleen appears as an accumu- 
lation of new, loose, connective tissue, in the meshes of which lymph-cor- 
puscles are found; later, follicles and pulp-substance appear, with a corre- 
sponding arrangement of blood-vessels. As these little organs always appear 
about the hilum of the spleen, they cannot be supernumerary spleens. After 
excision of wedge-shaped pieces of the spleen, formation of new spleen-tissue 
has also been observed upon the omentum at a point opposite the wound and 
independently from tissue-proliferation in the wound. Eeproduction of 
tissue therefore takes place in the same manner as in the regeneration of 
lymphatic tissue. After the removal of the entire spleen, tissue-proliferation 
takes place in the adjacent blood-vessels, the product of which corresponds 
with normal splenic tissue, and doubtless possesses the same physiological 
functions. As the immediate result of such proliferation, an altered condi- 
tion of the vessels must be accepted, as the blood-vessels of the omentum 



66 



PRINCIPLES OF SURGERY. 



and peritoneum correspond with the fundus of the stomach. Mayer claimed 
regenerative capacity for the pulp of the spleen, but he may have been de- 
ceived by the presence of lymphatic glands of the color of the spleen at the 
seat of extirpation. Picard and Malassez, Bizzozero and Salvioli, and finally 
Tizzoni and Fileti showed that after splenectomy a diminution of the blood- 
corpuscles is observed first, but as the new spleen-tissue is produced their 
number again increases. 

Lymphatic Glands. — Bayer and Bacialli have shown, by their experi- 
mental investigations, that new lymphatic tissue is rapidly produced after 
partial as well as after complete removal of a lymphatic gland. In the regen- 
eration of this tissue the adjacent adipose tissue appeared to take an active 




Fig. 47.— Wound of Kidney, Fourth Day. Large regeneration-cells of different forms 
(0); a, blood-extravasation containing new cells (c) produced by coalescence of leuco- 
cytes. (Tillmanns.) 



part. According to Bayer, the adipose tissue is first infiltrated with leuco- 
cytes, while Bacialli saw new endothelial cells and lymph-spaces develop 
from the connective-tissue cells, after having seen mitotic figures in the 
nuclei. After complete extirpation of a lymphatic gland, reproduction of 
lymphoid structure in all probability does not take place from any other but 
lymphatic tissue, and the new gland-tissue is the product of tissue-prolifera- 
tion from the cut ends of lymphatic vessels. 

Kidney.— The experiments of Turner have demonstrated that the kid- 
ney is endowed with a recuperative capacity which is common to nearly all 
of the glandular organs. They show that it is possible to successively re- 
move a large part of the normal renal tissue, and that, after a certain num- 
ber of days, — the sooner, the less renal parenchyma removed, — the specific 



CENTRAL NERVOUS SYSTEM. 



G7 



gravity of the urine and the excretion of urea are perfectly reestablished, and 
that compensation was due partially to hypertrophy of the remaining paren- 
chyma and partially to the new formation of glomeruli, and this happened 
even in cases of animals in which one kidney had already been extirpated, 
and was followed by a partial removal of the kidney on the other side. 
Turner, as a result of his experiments, states that, in animals, from 15 to 23 
grains of renal gland-tissue are sufficient for two pounds of weight. Esti- 
mating the weight of the human body at one hundred and forty pounds, 
from 1200 to 1500 grains of renal parenchyma, apart from the capsule, which 
is not counted, are sufficient to maintain life. This would amount to about 
one-third or one-fourth of the normal organ. Surgically, therefore, it is 
possible to remove a large part of the kidney, the remaining portion still 
retaining its function; and in partial destruction of the renal tissue it is 
not necessary to remove the whole organ, and we can be satisfied with a par- 




mm ^ ■ mM$^$MMB» ^ 



Fig. 48. — Healing of Wound of Liver, Tenth Day. a, young connective tissue; b, 
liver-tissue at the margin of the wound, showing fatty degeneration, and infiltrated with 
red and white blood-corpuscles. (Hartnack 3, oc. iii.) (Tillmanns.) 

tial excision, especially if the condition of the other kidney is not known. 
Partial excision may become necessary in injuries of this organ, in circum- 
scribed abscesses, and non-malignant tumors. Successful partial nephrec- 
tomy has been done by Herczl, Kiimmell, James Israel, and others. Success- 
ful partial nephrectomies have usually been performed for circumscribed 
inflammatory affections, and there is every reason to believe that the defect 
was repaired in part, at least, by regeneration to the same extent as in the 
experiments on animals. 



CENTRAL NERVOUS SYSTEM. 

The central nervous system is built up partly from the mesoblast and 
partly from the epiblast. The stellate and spider-shaped cells are derived 
from the mesoblast, while the neuroglia and the nerve-cells proper spring 
from the neuroblast, a part of the epiblast, which, in the embryo, is located 
nearest the middle axis. The neuroglia represent channels of nutrition, 



68 PRINCIPLES OF SURGERY. 

which are formed only at a time when the neuroblasts tissues have reached 
the height of their development. The mesoblastic portion of the brain and 
spinal cord does not increase during the healing of a wound of these parts. 
In pathological conditions, however, as in cases of multiple sclerosis, the 
stellate and spider-shaped elements proliferate so actively that the nerve- 
cells are completely displaced by the new product. Many authors have ex- 
pressed their doubts as to the possibility of regeneration of brain-tissue after 
injury or disease, while others have gone to the opposite extreme and claim 
that complete repair can take place in cases of extensive defects. Voit claims 
that in pigeons he has observed complete restoration of both structure and 
function, after extirpation of the entire cerebrum. Vitzow destroyed the 
occipital lobes in monkeys and found that vision which was completely de- 
stroyed was gradually restored. Histological examination proved that the 
restoration of sight was due to production of new nerve-cells and fibres. 
Tedeschi is somewhat skeptical on the subject of repair of large defects of 
the central nervous system. He produced wounds in the cortex of animals. 
As the immediate consequence of the injury degeneration and limited 
necrosis followed. However, in a short time a limited process of repair was 
initiated in the adjacent tissue. The endothelial cell formed capillaries and 
the neuroglia glia tissue, which constituted the main portion of the scar. 
Karyokinetic figures were seen in some of the ganglia-cells, and later nerve- 
fibres were also found in the scar, showing that a limited process of repair 
followed the primary degeneration. While large defects are not repaired, 
the regenerative capacity of the nervous elements cannot be doubted, and 
such a doubt would come in conflict with a general law. Eegeneration of 
the cerebral nervous system comprises the production of new ganglia-cells 
and neuroglia, the latter consisting of a fine net-work, sometimes of nervous, 
at others of basic, substance. During the healing of every wound of the brain 
the observer can satisfy himself that the neuroglia possesses a high capacity 
of reproduction, as well-marked karyokinetic changes can be seen during 
the first twenty-four hours after injury. The new cells are very abundant, 
and arrange themselves in groups. More difficult is the demonstration of 
the same changes in the ganglia-cells, but Mondino (1886) and Coen (1887) 
have given descriptions of these cells which leave no further doubt that they 
also multiply by karyokinesis. Klebs has also observed karyokinetic figures 
in the nuclei of ganglia-cells during the repair of injuries of the brain. In 
the embryo, increase of ganglia-cells by karyokinesis has been witnessed by 
Pfitzner, Uskorf, Eauber, Merk, and Cattani. It is true that brain wounds 
heal with some defects, but this applies to extensive injuries in which the 
regenerative capacity of the brain-substance is not equal to the emergency; 
hence, only a part of the defect is repaired. Klebs gives an accurate account 
of his examination on the reparative process in two cases of brain injury: 



CENTRAL NERVOUS SYSTEM. 69 

one recent, the other of long standing. Microscopical examination of the 
tissues from the seat of injury in both cases showed that new tissue had been 
produced. He found many new cells from the neuroglia which he is inclined 
to believe may functionally take the place of ganglia-cells. The same author 
made numerous experiments on young animals for the purpose of studying 
the process* of healing in wounds of the brain. With an aseptic needle the 
brain was punctured. No symptoms followed the injury. The brain was 
examined from two to four clays after puncture; only slight meningeal 
haemorrhage. The needle-track in the brain not closed. Mitotic changes 
were found, not in the cells in the immediate neighborhood of the puncture, 
but in the cells corresponding to from the second to the fifth row from it. 
In the same place were found an accumulation of resting nuclei. Mitotic 
cell-proliferation of injured cells was found completed on the fourth day. 
Ganglia-cells undoubtedly increase in number in the same manner. He 
found no leucocytes in the brain, and believes that those that must have 
been present had been appropriated as food by the cells which had under- 
gone karyokinetic changes. The gray matter of the surface of the brain is 
composed of numerous, but exceedingly small, cells, and their numerous con- 
nections would indicate great reproductive capacity. 

Peripheral Nerves. — When Cruikshank suggested the possibility of re- 
storing physiological function in a divided nerve by suturing, his contem- 
poraries regarded the suggestion as an absurdity. Since that time the sub- 
ject of nerve-regeneration has engaged the attention of some of the best 
men in the profession, and from the knowledge which has thus accumulated 
it is safe to repeat the statement made by Van Lair recently, that "tfre sur- 
geon who neglects to suture a divided nerve commits the same mistake as he 
who neglects to reduce* a fracture or fails to unite a divided tendon." Ee- 
generation of a nerve takes place exclusively from preexisting nerve-fibres. 
Schwann's sheath isolates the nerve-fibre so thoroughly from the mesoblast 
that it would be almost impossible for the latter to take any direct or active 
part in the regeneration of the former. The neuroblasts from which tissue- 
proliferation takes place are found within the nerve-sheath. Confluence of 
the new nerve-elements within the neurolemma does not take place, as, ac- 
cording to Cattani, they receive envelopes from the medulla. The part 
played by the cells of the sheath of Schwann in the regeneration of nerves 
has become to be a moot question. Yon Bungner, Galrotti and Levi, Ziegler 
and von Wieting have claimed that these cells are a kind of neuroblast the 
protoplasm of which gives origin to parts of the new axis-cylinders. Ivolster 
and Huber traced the formations of the myelin in the regenerating nerve 
to differentiation in the protoplasm of Schwann's cells, while others main- 
tained that the myelin-sheath grows down simultaneously with the axis- 
cylinders. Section of a motor fibre is at once followed bv defeneration of 



70 PRINCIPLES OF SURGERY. 

the motor terminal part; hence, degeneration and regeneration in the 
divided nerve and the muscles supplied by it are parallel processes. Degen- 
eration and regeneration have been studied in nerves that were stretched, 
lacerated, or completely cut across, and the histological processes were found 
almost identical in all of these conditions. The study of degenerative and 
regenerative processes side by side in injured nerves has thrown much light 
upon their minute anatomy. The medullated peripheral nerve-fibres is com- 
posed essentially of Schwann's sheath, the axis-cylinder, and a fluid which 
appears as a periaxial layer. Klebs looks upon this fluid as a sort of nervous 
endolymph, which, by virtue of its great mobility, takes part in the nutri- 
tion of the nerve. The space which contains the fluid, being between the 
axis-cylinder and the sheath, serves not only the purpose of a channel for 
the fluid, but also for the dissemination of movable elements, — as, for in- 
stance, migration-corpuscles. Leucocytes are only present in any consid- 
erable numbers in pathological conditions. Schwann's sheath is composed 
of connective tissue. The large oval nuclei, containing each one or two 
shining nucleoli, which are attached to its inner side, are the neuroblasts. 
It is as yet not definitely settled whether the portion of nerve between two 
of Eanviers constrictions is composed of one or more cells. Eeclus accepts 
Eanvier's theor}^, that the new nerve-elements originate from the axis- 
cylinder of the central end, and generally from Eanviers ring nearest the 
section. A single myelin-fibre is produced here, or an axis-cylinder which 
later is enveloped by myelin. From this tube new tubes are formed, finally, 
from twenty-five to forty in number, which approach the peripheral end, 
insinuate themselves into empty Schwann's sheaths or the spaces between 
them. Klebs is inclined to accept the view that such a space is represented 
by one cell, and if several nuclei are present they are' the product of nuclear 
segmentation. The nuclei must be regarded in the light of peripheral nerve- 
cells. The specific functional contents of a nerve-fibre are the axis-cylinder, 
the endolymph, and medulla. The first two are continuous with the neigh- 
boring elements, but not so the medullary sheath. The medullary sheath is 
a very complicated structure. The masses of fat are held together and are 
inclosed by a frame-work of keratin. Finer keratin-threads unite both 
sheaths in the form of Golgf s spirals, which are present in the funnels of 
Schmidt-Lautermann's medullary spaces; besides, numerous transverse 
threads are strung out in zigzag shape between the sheaths. The constituent 
parts of the medullary portion of the nerve-fibre can disappear separately; 
if the medullary fat is removed by absorption, the keratin frame- work be- 
comes visible: a condition which is present during the early stages of neu- 
ritis parenchymatosa. If the keratin frame-work is dissolved, the fat ap- 
pears in drops, as can be seen during the degeneration of a nerve after sec- 
tion. The axis-cylinder is a preexisting structure, which, however, can be 



CENTRAL NERVOUS SYSTEM. 



71 



only distinctly outlined against the medullary sheath and endolymph by 
post-mortem influences. Its structure, in the larger mednllated fibres at 
least, is not simple, but is composed of fine fibrillar held together by an 
amorphous, gelatinous substance. Physiologically, this part of the nerve 
must be regarded as a complex of different conductors, which only differ by 
the qualities of motility and sensibility. Regeneration of a peripheral nerve- 
fibre is a regular typical process, as far as it serves as a substitute for lost 
elements of a nerve. The process resembles the physiological growth of a 
nerve, which always occurs only in connection with the central nervous sys- 
tem. If the separation between the nerve-ends exceeds an inch, restoration 
of its continuity without assistance cannot take place. In such an event the 
ends become bulbous, the medullary substance in the distal portion under- 
goes degeneration, and the axis-cylinder becomes more and more indistinct. 
The same changes take place in the nerve-ends after amputation. When a 




Fig. 49.— Tubular Suture of Van Lair with Decalcified-Bone Tube. Transverse Sec- 
tion, a, concentric fissures; b, radiating fissures; c, central canal, showing new nerve- 
fibres. 

nerve is simply divided and there is no loss of substance, the ends remaining 
in close contact, function is established in a remarkably short time. In two 
instances Gluck observed perfect function within twenty-four hours. He 
concludes that the granulation-tissues must have been the means of conduc- 
tion in these cases. In his experiments on the sciatic nerve in fowls, where 
he divided the nerve and immediately sutured with catgut, function was re- 
stored in from fifty to eighty-six hours. Waller and Van Lair are of the 
opinion that regeneration proceeds entirely from the proximal end. Ac- 
cording to Van Lair, the zone of proliferation extends one and one-half to 
two and one-half centimetres above the divided end, and the new material is 
principally furnished by the cortical tubes. The young fibres may attain a 
length of from one to even six centimetres; beyond this distance they require 
the support of empty nerve-sheaths. If such a support is not present the 
new fibres cease to grow and undergo atrophy. When there is a space be- 



72 



PRINCIPLES OF SURGERY. 



tween the severed nerve-ends, the fibres easily penetrate through the cica- 
tricial tissue as long as it is embryonal. Upon this observation are based 
the experiments of Yan Lair, who secured union between nerve-ends widely 
separated by interposing between them a decalified-bone tube, the new nerve- 
fibres following the Haversian canal or the fissures caused by absorption. 

By Van Lair's method a distance of six to seven centimetres has been 
successfully bridged. The time required in the repair of such large defects 
depends on the age of the patient, — from three to eight months. Colasanti 
claims that degeneration of the peripheral end only extends as far as the 




Fig. 50.— Nerve-fibre in a State of Regeneration Fifty to Seventy Hours after In- 
jury. A, proliferation of neuroblasts; B, spindle cell, which, becoming confluent with 
similar cells from both sides, unites the nerve-fibres; C, rows of spindle cells, forming 
amyelinic nerve-fibres; D, young amyeloid cells, formed from nuclei of neurolemma. 
(Gluck.) 



next Eanvier ring, while Tizzoni found that degeneration extends from the 
seat of injury in both directions, only that it is more marked on the distal 
side. Most of the recent writers on the subject assert that when a piece of 
the nerve is resected the entire nerve on the distal side undergoes degenera- 
tion, while, if the nerve is only divided and the ends are immediately sutured, 
at least a number of the nerve-fibres retain their integrity. Eichhorst and 
others, who have made regeneration of the nerves a special study, are of the 
opinion that the nerve-fibres of both ends participate in the process of repair, 
and that regeneration commences with degeneration. Eichhorst believes 
that regeneration takes place exclusively by splitting of the axis-cylinder 



CENTRAL NERVOUS SYSTEM. 73 

within Schwann's sheath, so that the latter in the course of time becomes 
distended with the product of proliferation. Continuity is restored by the 
central fibrils being pushed outward through the cicatrix to meet the periph- 
eral, and coalescence follows. Beneke, on the other hand, traced the origin 
of the new fibres to protoplasm of the neuroblasts, which are transformed 
into delicate fibrils, which become surrounded by a coating of myelin: the 
future medulla. It is more probable that regeneration of a nerve takes place 
by the latter method. After a trauma reproduction of the axis-cylinder al- 
ways follows. According to a number of investigators who have studied this 
subject, several axis-cylinders are formed within each Schwann sheath, each 




Fig. 51.— longitudinal Section through Nerve Twenty-one Days after Injury, show- 
ing Medullated and Non-medullated Nerve-fibres with Round Cells between them. 
(Gluck.) 

of which is surrounded by a separate medullary sheath. It is difficult to 
ascertain whether these new fibres, growing out of one of the old fibres, again 
become united some distance toward the periphery, or whether they remain 
isolated to their point of peripheral distribution. After nerve-section the 
axis-cylinder swells at the cut end and becomes striated; this swelling, how- 
ever, is not an active process, but the result of imbibition of stagnant endo- 
lymph. The longitudinal striations and formation of vacuoles which have 
been described by Tizzoni are due to the same cause. The granular appear- 
ance is brought about by disintegration of the fibrillas. The old axis-cylinder 
breaks down into isolated fragments, which, in part at least, are removed by 



74 PRINCIPLES OF SURGERY. 

leucocytes, which at this time have made their appearance. With such ex- 
tensive destructive changes in the axis-cylinder it is difficult to conceive how 
regeneration of this structure could take place in the manner described by 
Eichhorst. The only histological elements within the fibre-sheath exempt 
from degeneration are the nuclei of the inner surface of the sheath, the neu- 
roblasts, and from these regeneration takes place. 

At the seat of regeneration the nerve is enlarged from the accumulation 
of the products of tissue-proliferation within the neurolemma-sheaths. 

The first stage of regeneration of a nerve is initiated by multiplication 
of the neuroblasts and increase of protoplasm. The nuclei increase to double 
their normal size and then divide into two or more. Division of nuclei prob- 
ably takes place by karyokinesis. The protoplasm is granular, and is stained 
a reddish color with neutral picrocarmin. The nerve-fibre originates from 
the protoplasm, and, according to Tizzoni, in the form of separate pieces, 
around which already can be distinguished a medullary sheath and trans- 
parent contents. In other cases there may be a direct connection between 
the old and new axis-cylinder. Longitudinal striation of the axis-cylinder 
probably takes place at a. time when the fibre has formed a direct connection 
with distant parts, the seat of active physiological processes. Leucocytes 
have been found within the neurolemma by Tizzoni and Korybut-Daskiewicz, 
while Neumann denies their presence in this locality. Cattani believes that 
they are present within the fibre-sheath after nerve-stretching, and can be 
found as far as the motor ganglia of the cord. Nerves of different function, 
when united, will undergo repair and establish useful conductors for the 
transmission of nerve-force. The late Professor Gunn established the cor- 
rectness of this assertion by a series of interesting experiments on dogs. 
Early functional results after nerve-suture are often fallacious, as the func- 
tion attributed to sutured nerves may be performed by other nerves which 
reach over such areas; and, again, the peripheral manifestation may be the 
result of physical conduction of the irritation, and apparent motor recoveries 
may be stimulated by the action of muscles other than those supplied by the 
sutured nerve. 

NERVE-SUTURE. 

Nerve-suture was first performed by Baudens in 1836, with negative 
result. The procedure was revived by Nelaton in 1863, and the following 
}^ear by Langier. The first operations were made with fine-silk sutures, 
which were not cut short, and subsequently came away by suppuration. 
Failures will occasionally follow both primary and secondary nerve-suture 
in spite of good coaptation, as such results may be due to secondary degen- 
eration of motor nerve-cells in the cord, as was suggested by Willard. 0. 
Weber advised the uniting of the nerve-ends by passing the sutures, not 



NERVE-SUTURE. 



75 



through the nerve-substance, but only through the connective tissue sur- 
rounding the nerve: the paraneural suture. Experience, however, has shown 
that transfixion of the nerve-ends by the sutures does not give rise to pain, 
and does not interfere with the normal reparative processes, and at the same 
lime, by resorting to this direct method of suturing, more perfect coaptation 
is secured. In the case of large nerves, it is advisable to reenforce the direct 
sutures witli a number of paraneural sutures. The best material for the su- 
tures is aseptic catgut. An ordinary sewing-needle with a dull point is pref- 
erable to a surgical needle, as it is more sure to pass through the nerve 
without injuring the fibres. 

From one to three direct sutures, according to the size of the nerve, are 
applied, and from three to six paraneural sutures. The needle is passed 
straight through the nerve on each side, one-eighth to one-fourth of an inch 
from the ends, and care must he exercised, in tying the sutures, to bring the 
cut surfaces in accurate apposition, and not to tie the sutures too tightly, 



DlrcctSutan 



JPara iwural 
Suture 




Fig. 52. — Nerve-suture, showing Application of Direct and Paraneural Sutures. 



as by doing so the nerve-ends are liable to become displaced by overlapping. 
In tying the paraneural sutures the necessary precautions must be taken to 
prevent the margins of the sheath from insinuating themselves between the 
nerve-ends. 

Primary Nerve-suture. — A primary nerve-suture is one used to unite 
a nerve immediately or soon after the injury has occurred, and before any 
degenerative changes have taken place. It should always be resorted to in 
the treatment of accidental wounds where one or more nerves have been 
divided, also where in operations a nerve has been divided accidentally, and, 
finally, in cases where a neurectomy for pathological conditions cannot be 
avoided. The results after primary suture have been very satisfactory. 
Brims has collected 71 cases from different sources, and in more than 33 per 
cent, of the number function was restored. As suppuration in a wound where 
a nerve has been sutured would, in all probability, cause tearing out of the 
sutures and displacement of the nerve-ends, it is of the greatest practical 



76 PRINCIPLES OF SURGERY. 

importance to secure for such wounds an aseptic condition and to obtain 
primary union throughout, and consequently no provision for drainage 
should be made. If the wound-surfaces cannot be approximated, and a 
greater or less space has to fill up by granulation, a bundle of catgut-threads 
can be used for a capillary drain, in order to avoid tension from the accu- 
mulation of blood or the primary wound-secretion. 

Secondary Nerve-suture. — When a divided nerve fails to unite, the ends 
become bulbous, are usually found imbedded in a mass of cicatricial tissue, 
and separated from each other from one to two or more inches. The bulb- 
ous enlargement of the proximal end remains permanently and is often a 
useful guide to the nerve in cases requiring secondary nerve-suture. Func- 
tion below the point of division is completely lost; the distal portion of the 
nerve itself, being no longer in connection with the central nervous system, 
undergoes degeneration, and the muscles supplied by the injured nerve be- 
come atrophic and useless. The reuniting of such a nerve is done by the 
secondary suture. Experience has shown that function can be restored by 
this procedure years after the injury. Jessop vivified the nerve-ends and 
applied sutures nine years after injury of the median nerve, and restored 
function. Langenbeck sutured the sciatic nerve two years after division; 
sensation returned in three days, and, later, motion. As a rule, sensibility 
returns first after nerve-suture, followed considerably later by restoration 
of motor function. The most speedy restoration of function, both sensory 
and motor, after secondary suture is reported by Tillaux. He operated on 
the median nerve three years after division. The ends were found imbedded 
in a cicatrix and separated from each other four centimetres. The ends 
were vivified and sutured. He claimed that physiological function was re- 
stored completely three hours after the operation. There can be no doubt 
of the ultimate recovery of nerve-function in this case, but that this should 
have been attained in three hours appears next to impossible. Enough has 
been said to show that secondary nerve-suture can be resorted to with good 
prospects of success years after an injury, but for well-known reasons it 
should not be postponed after it has become evident that union has failed 
to take place. Unnecessary delay is dangerous, because when a nerve has 
become permanently disconnected from the central nervous system muscular 
degeneration goes hand in hand with degeneration of the distal portion of 
the nerve, and, the longer the operation is delayed, the greater the length 
of time required to complete the regeneration of the nerve and the muscles. 
The first secondary nerve-suture was made by Xelaton in 1865. In Ger- 
many the first operation was made by Gustav Simon in 1876, and he was 
followed by Langenbeck the following year. In 1884 Bruns found 33 re- 
corded cases, and in 24 of this number the result was satisfactory. As a 
rule, sensation returned gradually in from two to four weeks, while motion 



NEBVE-S1 ri RE. 77 

did not return until throe weeks to three months after the operation. Com- 
plete restoration of function was seldom completed until half a year to one 
year after the operation. As in cases which require secondary suture the 
nerve-ends are sealed with a mass of cicatricial tissue, it is always necessary 
to resect the ends, after which the sutures are applied in the same manner 
as in primary nerve-suture. Both nerve-ends must be freed from all cica- 
tricial adhesions before approximation is attempted, and, if this cannot 
be readily done on account of previous retraction, both ends are carefully 
stretched and sufficient elongation secured so as to prevent any tension upon 
the sutures. A great deal can be done to prevent tension by placing the 
limb in such a position as will relax the nerve; for instance, flexion of the 
hand and forearm in suturing the ulnar, median, or musculo-spiral, and 
flexion of the leg and extension of thigh after reuniting the sciatic. The 
position of the limb most favorable for the union of a sutured nerve is best 
secured by a plaster-of-Paris dressing, w T hich is allowed to remain not only 
till the external wound is healed, but until the nerve has firmly united. 
When a nerve has suffered a considerable loss of substance at the seat of in- 
jury it is often found impossible to bring their ends in contact by nerve- 
stretching and position of limb, and in such cases restoration of continuity 
becomes an exceedingly difficult task. 

Letievant suggested that the defect in such cases should be corrected 
by a neuroplastic operation. He proposed that a flap should be taken from 
each end sufficiently long that, when turned toward each other, they could 
be sutured at the middle of the defect, thus making a connecting bridge of 
nerve-tissue between the separated nerves. (Fig. 53.) As could be expected, 
in a case where he performed this operation the result was negative. In a 
case operated on by Tillmanns after this method, partial restoration of func- 
tion was established three and a half months after the operation. The suc- 
cess in this case was probably not the result of conduction of nerve-force 
along the fibres of the flaps, but the production of new fibres across the gap, 
perhaps through the tissues composing the temporary bridge. The same 
author devised for a similar class of cases what he calls cross-sutures (Fig. 
54), where the nerves are cut at a different level and the ends separated too 
far for any direct method, suitable in the median and musculo-cutaneous in 
the arm or the median and cubital nerve in the forearm. The two longer 
ends are united by direct suture and the shorter ones grafted into the ad- 
joining trunk. The success of this operation is based on the physiological 
law of the conductibility of nerve-fibres. This operation has resulted suc- 
cessfully in a number of instances in the human subject. From his experi- 
ments on animals, Gluck came to the conclusion that nerve-defects could 
be corrected by transplantation of nerves; that is, inserting a piece of nerve 
from an animal, corresponding in size to the nerve to be reunited, between 



78 



PRINCIPLES OF SURGERY. 



the nerve-ends, and uniting it with them with sutures. He reports a num- 
ber of successful experiments on chickens, filling the gap with a nerve taken 
from rabbits. Philipeaux and Vulpian, from their own researches, came to 
the conclusion that a transplanted nerve always degenerates and disappears, 
and that restoration of structure and function only takes place by regenera- 




Fig. 53. 



Fig. 54. 



Fig. 53. — Neuroplasty. A, upper end; A', lower end; H, H', flaps turned toward 
each other; D', B' , suture of the two flaps; B, D, level of section of flaps. (After 
Letievant.) 

Fig. 54.— Cross-suture. 1. The ends A B and C D are too far apart to be sutured; 
the upper end (C) of the nerve will be united with the lower end (B) of the other nerve. 
2. Completed suture; the ends A D are implanted into the adjoining nerve-trunk. (Till- 
manns.) 



tion from the nerve-ends. It is probable that the methods of nerve-restora- 
tion devised by Letievant and Gluck are useful in reuniting separated nerve- 
ends in the same manner as the suture a distance of catgut suggested by 
Assaky. The interposition of an aseptic, absorbable substance like catgut 



NERVE-SUTUBE. 79 

or nerve-tissne serves as a temporary scaffolding for the products of tissue- 
proliferation from the nerve-ends, which at the same time determines the 
direction for the new material, providing the shortest route to meet the same 
material from the other side. When catgut is employed two or three sutures 
are used, so that the combined size of the strings will at least approximately 
correspond to the size of the nerve. Van Lair, who believes that regenera- 
tion of a nerve takes place exclusively from the proximal end, resected a piece 
of the sciatic nerve in dogs, and then sutured both ends of the nerve to the 
ends of a decalcifled-bone tube, which in length corresponded to the section 
of nerve removed. From the results of his experiments, ten in number, he 
became satisfied that continuity of the nerve was restored by the new nerve- 
fibres from the proximal end growing into the tunnel, bridging the defect in 
a comparatively short time, as they had no resistance to overcome, and 
uniting with the end of the nerve on the opposite side of the tube. It ap- 
pears to the author that this method of overcoming the difficulties of re- 
uniting nerve-ends widely apart is not only an ingenious procedure, but, if 
applied in practice, promises better results than any other method hereto- 
fore proposed. In certain cases where the distal end cannot be found, or 
where the separation is so great that none of the methods of approximation 
so far devised hold out any inducements of a successful issue, Letievant sug- 
gested the idea of grafting the central end upon the intact trunk of a neigh- 
boring nerve. This operation failed in his hands, but Tillaux and Tillmanns, 
slightly modifying the method, were successful. In Tillmanns' case the 
ulnar nerve had been divided, the ends were found separated four and one- 
half centimetres, and the proximal end was grafted upon the median nerve. 
Sensation returned in a month, and by using electricity and massage recov- 
ery was complete a year later. Xerve-grafting, as advocated by Letievant, 
should only be resorted to after implantation of a decalcifled-bone tube be- 
tween the nerve-ends has been tried and proved a failure, or in cases where 
the defect is very extensive, or, finally, if, after the most diligent search, the 
distal end cannot be found. Eestoration of function does not always follow 
after the continuity of a nerve has been restored by operative measures. 
Ehrmann has reported such a case. The radial nerve was divided below the 
elbow and failed to unite. Complete paralysis of all the muscles supplied 
by this nerve. After the lapse of seven months the nerve was exposed, and 
the ends, which were five centimetres apart, were vivified and sutured. 
Seven months after the operation, no improvement. The nerve was again 
exposed at the former site of operation, and it was found that union had 
taken place, but the nerve was compressed by a firm cicatrix two or three 
centimetres in length. The nerve was relieved from its imprisonment, and 
when the faradic current was applied all the muscles supplied by the nerve 
responded. Four months later, complete recovery. This case reminds us 



80 PRINCIPLES OF SURGERY. 

of the importance of securing healing of the nerve and wound with as little 
cicatricial tissue as possible, which can only be done by absolute asepsis and 
careful attention to suturing of the wound. 



CHAPTER III. 

Degeneration. 1 

Degeneration is the counterpart of regeneration. Regeneration is an 
active cellular process which, results in the formation of new tissue within 
normal physiological limits, while degeneration consists of cell-changes 
which lead to atrophy or complete destruction by processes in which the 
protoplasm of the cells takes no active part. Regeneration is an active build- 
ing-up process in which the products of tissue-proliferation are utilized in 
the formation of new tissue or in replacing tissue destroyed by injury or. dis- 
ease. On the other hand, degeneration consists in the waste or destruction 
of existing tissue by inadequate nutrition or noxious extrinsic influences 
which destroy cell-life and activity. It is proper that the subject of degen- 
eration should be discussed after the student has familiarized himself with 
the nature and histology of regeneration and before he begins to study the 
complicated processes which characterize inflammation, and because, in 
every inflammation, cell-destruction is a constant feature, and also because 
there is no inflammation so severe but what, somewhere in the infected field 
or in its periphery, attempts at repair can be seen. 

Regeneration is characterized by karyokinesis, — great cell-activity; 
degeneration by nuclear fragmentation, karyolysis, and cell-destruction. 

ATROPHY. 

The simplest form of degeneration is atrophy. It is caused by defective 
nutrition. It may be limited to isolated cells, a part, or organ, or may impli- 
cate the entire body, according to the extent of the etiological influences. As 
a normal condition, it is seen in some of the organs of the body after periods 
of high physiological activity, and is then known as involution-atrophy. Gen- 
eral atrophy attends old age, and follows acute and wasting diseases and any 
affections which interfere with digestion, absorption, and assimilation of food 
or defective food-supply, and is then called marasmus. Atrophy from pro- 
longed non-use is termed inactivity - atr o pliy . It is seen most frequently as 
one of the constant results in advanced cases of joint tuberculosis. In 
atrophy the macroscopical and microscopical changes are more of a quanti- 
tive than qualitative nature, the essential etiological feature consisting of a 
defective substitution of nutritive material, and the conditions would be de- 



1 The author desires to acknowledge his indebtedness to Perls' "Pathologie" for valu- 
able information in preparing this chapter. 

(81) 



82 



PRINCIPLES OF SURGERY. 



scribed more correctly if the term aplasia were substituted for what is 
usually understood and described as atrophy. The atrophy of fat-tissue pro- 
duced by the withdrawal of food in animals has been studied most carefully 
by Flemming, who ascertained that in the cells deprived of their fatty con- 
tents in this manner an active multiplication of nuclei and production of 
young cells takes place whereby a microscopical picture is created which very 
much resembles inflammatory tissue. Similar observations were made by 
Grawitz and his pupils in atrophy of muscles and nerves. Kolliker regards 
the giant cells in the myeloid tissue as the essential agents in the production 
of atrophy of bone, and excavation of Howship's lacunae as their almost spe- 
cific product. Eustitzki believes that these cells secrete an acid substance 




Fig. 55. — Ischsemic Paralysis of Muscles of Leg Following Degeneration Produced by 
Scar-contraction after an Extensive Burn. Large Circular Ulcer Remained Unhealed. 



which dissolves the earthy constituents. Atrophy of muscles after section 
of the motor nerves, with or without fat-formation, can reach a consider- 
able degree after a few months. On the other hand, muscle-degeneration 
and atrophy the result of ischaemia sets in within a very few days, and 
leads to permanent results, as has been shown by Volkmann, Leser, and 
others. This form of muscle-atrophy is observed most frequently in conse- 
quence of harmful constriction by fixation dressings in the treatment of 
fractures, but has also been seen as a remote consequence of cicatricial con- 
traction, more especially after extensive burns of the extremities. Muscle- 
degeneration from defective blood-supply is better known under the term 
ischemic paralysis. (Fig. 55.) Progressive hemiatrophy of the face is gen- 
erally regarded in the light of a trophoneurotic disturbance. 



CLOUD'S SWELLING. 83 



CLOUDY SWELLING. 



Degenerative changes in the protoplasm of living cells depend Largely 
on modifications of their albuminous contents. It is difficult to determine 
in individual instances whether such modifications are caused by chemical or 
physical influences. Bacteriological investigations have opened up a wide 
field for investigation in this direction, as it is now well known that many 
cell-degenerations, both of the acute and chronic type, are caused by toxic 
substances eliminated from pathogenic bacteria. In most of the acute in- 
fective diseases cell-degeneration in different parts of the body is a constant 
feature and produced solely by toxins elaborated in the tissues or brought in 
contact with them through the medium of the general or lymphatic circula- 
tion. The most frequent form of retrograde tissue-metamorphosis is the 
cloudy swelling, known also as albuminous infiltration or metamorphosis, 
granular degeneration, and parenchymatous degeneration. 

The parenchyma-cells are usually affected by this form of degeneration, 
and hence the designation "parenchymatous degeneration/' The con- 
nective tissue, if affected, does not show the pathological conditions as 
plainly. The organs and tissues the seat of cloudy swelling are somewhat 
enlarged, softened, pale, and of a dirty-gray color; the normal outlines of 
glandular structures obscured, and the transparency of the tissues is dimin- 
ished. Under the microscope the cells exhibit a granular appearance; the 
granules are very fine, refract light feebly, and impart to the cell-protoplasm 
a dusty, cloudy appearance, which, in the muscle-fibre, for instance, obscures 
the nuclei and striations. The cells are enlarged, their form irregular, and 
outlines ill defined. Acetic acid clears up the protoplasm, and the nuclei 
become more distinct. The granules are degenerated albuminous products, 
which are dissolved by the acetic acid. Cloudy swelling is constantly seen 
in acute infectious diseases, phosphorus poisoning, and catarrhal inflamma- 
tion. Cloudy swelling often precedes fatty degeneration, cell-death, or also 
proliferation. 

Yirchow, who first described cloudy swelling, found it during the early 
stage of parenchymatous inflammation. It was discovered, however, later, 
that in most instances it is present in patients the subjects of acute infectious 
diseases, in organs which were not the seat of inflammation. The textural 
changes in the protoplasm of the cells point either to an increased supply 
of albuminoid substances or a modification (coagulation) of the existing 
cell-contents into a less soluble substance. It is very probable that in inflam- 
mation the former and in acute infectious diseases the latter process takes 
place. The destructive effect of toxins on cells is well known, and we can 
safely assume that the degree of parenchymatous degeneration is determined 
largely by the amount and virulence of the toxins which are brought in con- 



84 PRINCIPLES OF SURGERY. 

tact with the cells, in this respect resembling the toxic effects of phos- 
phorus. 

FATTY DEGENERATION. 

An advance in the regressive metamorphosis of cloudy swelling leads 
to fatty degeneration. In fatty degeneration the contours of the granules 
are more sharply defined, the dusty appearance is changed into a dotted 
field, the groups of molecules appear clear and, when dense, present an al- 
most black appearance. (Fig. 56.) These granules are not altered albumen, 
but fat, which takes the place of albumen. In acetic acid the normal cell- 
contents are cleared up, but the granules remain unchanged; hence, can be 
seen more distinctly. These fat-molecules are soluble in ether. The gran- 
ules vary much in size, those of medium size corresponding with the red 
blood-corpuscles. If the degeneration is far advanced, these granules co- 
alesce into larger masses, and crystals make their appearance. As the cells 




Fig. 56. — Fatty Degeneration of the Heart-muscle in Pernicious Anaemia. Fat Stained 
Black with Osmic Acid. A, fat-droplets. 

and tissues involved in the fatty degeneration are not increased in size we 
have no reason to assume that preformed fat was supplied, but are forced to 
the conclusion that it is an intracellular product. In degenerative lipogene- 
sis the fat is probably formed from the constituents of the cell, which suffers 
grave protoplasmic and nuclear lesions. Lindemann takes it for granted that 
fat can form from albumen, although Pfliiger, Eosenfeld, and others take an 
opposite view. Lindemann lays stress on the formation of fats from pro- 
teids by bacteria, as is supposed to be the case in the production of adi- 
pocere, and which might therefore occur in infections. As pointed out by 
Taylor, even though we admit that fat is formed in degenerated cells, it can 
still be claimed that it is a chemical product from carbon compounds — sugar, 
glycogen, glucosides, and mucin — which abound in cells rather than from 
the proteids: a contingency which Lindemann does not consider suffi- 
ciently. Occasionally fatty degeneration is associated with the formation of 
a substance which resembles the coagulated medulla of nerves (myelin de- 
generation). This combination of degenerative processes is seen most fre- 



FATTY DEGENERATION. 85 

quently in the alveoli of the lungs. This substance is probably liberated 
lecithin, which, when dissolved in water, assumes the myelin form. If the 
fatty degeneration is far advanced and extensive, a mass is formed composed 
of free fat-globules, remnants of protoplasm, and nuclei, which is known as 
fatty detritus. In old deposits of this kind fat-crystals — so-called margaric- 
acid needles — make their appearance. Besides these delicate soft crystals 
plates of cholesterin isolated and in masses mark the advanced stage of the 
degenerative process. Fatty degeneration is a very frequent tissue-change. 
All those causes which have been enumerated in connection with simple 
atrophy and cloudy swelling produce fatty degeneration; very often we 
find the latter side by side with the two first conditions and occasionally 
all coexist at the same time. A mild form of fatty degeneration con- 
stantly takes place in most of the tissues as an expression of the con- 
stant changes incident to the substitution of new for old cells, and in the 
aged it is almost constantly found in the intima of the large blood-vessels, 
as well as in the walls of the small arteries of the brain, and occasionally also 
in the parenchyma-cells of the organs which undergo atrophy. As a patho- 
logical process we find fatty degeneration, in the first instance, as a local 
affection limited to certain parts of the body, and, in the second place, as 
an acute and diffuse lesion involving different organs and tissues. The 
localized form is caused either by a defective blood-supply like simple atro- 
phy, or increased tissue-destruction with impaired resorption and imperfect 
restitution, caused either by a disproportion between action and rest, by 
impairment of the blood- and lymph- circulation, by ferment — or similar 
influences which are destructive to the cell-contents. Inflammatory proc- 
esses are frequently the direct cause of quite extensive fatty degeneration 
of the fixed tissue-cells, but more particularly of the cells in the exudate 
derived either by cell-migration or proliferation. After nerve-section fatty 
degeneration takes place in the peripheral end. Eight to ten days after 
section of a nerve the homogeneous medullary substance around the axis- 
cylinder breaks up into irregular clumps varying in size, which in a few days 
become smaller and present the appearance of droplets of fat, which dis- 
appear slowly; so that after about two months only the axis-cylinder and the 
collapsed neurilemma remain. Of the greatest interest are those obscure 
cases in which acute fatty degeneration takes place simultaneously in sev- 
eral organs. In acute infectious diseases the cloudy swelling is not infre- 
quently followed by fatty degeneration. In other cases of acute diffuse fatty 
degeneration attended by icterus and punctiform ecchymoses poisoning with 
phosphorus or arsenic was shown to be the cause of death. It is in such 
cases that the parenchyma-cells of the liver exhibited in a most marked man- 
ner the condition known as fat-infiltration. The same condition is found 
in acute atrophy of the liver. Acute fatty degeneration of different organs 



8(i PRINCIPLES OF SURGERY. 

with pimctiform extravasation of blood has also been found in connection 
with progressive pernicious anaemia; the organs principally involved were 
the heart and blood-vessels. Although fatty degeneration and fat-infiltra- 
tion resemble each other in many respects, they constitute two different 
pathological processes. By fat-infiltration is understood the deposition of 
preformed fat in the tissues, while in fatty degeneration the fat is produced 
from the cell-contents by the conversion of the protoplasm into fat. The 
latter takes place when the organ is supplied with an excess of fat or when 
the existing fat fails to disappear by normal processes which regulate the 
supply and waste of this constituent of the body. The artificial fattening 
of animals furnishes a good illustration of what we mean by fat-infiltration. 
In some animals — especially the domestic goose — thus treated the liver be- 
comes the principal depot for the deposition of the surplus fat. In contra- 
distinction to the liver the seat of fatty degeneration, in fat-infiltration the 
organ becomes very much enlarged, the capsule tense, anterior border thick 
and rounded, and the parenchyma fragile. The cells are filled, not with 
granules, but large droplets of fluid fat densely crowded together. The 
amount of fat in fat-infiltration is much greater than in fatty degenera- 
tion. Tor instance, in fatty degeneration of the heart the fat seldom ex- 
ceeds one-fourth of the heart in weight, while, on the other hand, in fat- 
infiltration it often reaches one-half to four-fifths. 

MUCOID. COLLOID, AXD WAXY DEGEXERATIOX. 

Mucin is a degenerative product of the protoplasmic contents of cells. 
This substance is characterized by its intrinsic properties to absorb water to 
an unusual extent. Filtration, even when much diluted, is exceedingly dif- 
ficult, and the apparent solution is exceedingly viscid and can be drawn 
out into fine threads. It differs from other albuminous substances in that 
on the addition of acetic acid it is precipitated in the form of white flakes 
which, on adding an excess of acetic acid, are not dissolved; if it is precipi- 
tated by alcohol, it appears under the microscope usually, not in the form 
of granules, but as a fine fibrillated deposit, and is free from sulphur. It is 
this substance which imparts to the different mucous secretions their viscid 
property. It is found also in a normal condition in the vitreous humor of 
the eye and in the umbilical cord. As a pathological product we find mucin 
in cells as well as in the intercellular substance. In the former as a quan- 
titative increase of the plrysiological metamorphosis in catarrhal and inflam- 
matory affections of the mucous membranes, the mucous glands are en- 
larged and filled with mucin-globules; their cells are also greatly swollen 
by the accumulation of mucin: others rupture and are destroyed. In the in- 
tercellular substance — especially that of cartilage and bone — also in tumors 



MUCOID, COLLOID, AM) WAXY DEGENERATION. 87 

mucin-production takes place occasionally in inflammatory processes as well 
as during passive conditions, ai times with diminished coherence of the tis- 
sue: so that a mucoid softening takes place: this softening can increase 
tmtil liquefaction ensues, with the formation of cysts filled with a mucoid 
substance and detritus of cells. 

An exclusively pathological product, the result of degeneration, is 
what is known and described as colloid substance. It differs from mucin 
in being more consistent and presents itself macroscopically in the form of 
boiled sago with at times a yellowish tint of color. The jelly-like substance 
is not affected by alcohol and acetic acid. The colloid degeneration of cells 
is very similar to the mucoid, the same droplet formation in the protoplasm, 
only that the globules are firmer; but it appears that the colloid masses can 
form in albuminoid fluids independently of cell-activity. The thyroid 
gland is the organ which exhibits most frequently colloid masses in greatest 
amount, and miasmatic struma consists largely of a distension of its follicles 
with honey-like homogeneous masses. According to Yirchow, the colloid 
substance is not the product of cell-transformation, but it represents the 
inspissated fluid rich in sodic albuminate transuded into the follicles. Col- 
loid formation also takes place in the parotid, prostate, and ovaries. The 
surface of the masses is covered by epithelial cells, and in the middle of the 
substance besides remnants of epithelial cells will be found granules of albu- 
men and fat and often drops of a thinner fluid. In the course of time the 
colloid substance becomes firmer and more brittle. Mucoid and colloid de- 
generation are often seen side by side, especially in tumors and cysts,. often 
combined with other regressive metamorphoses. 

Eecklinghausen has described a degenerative process under the name 
hyaline degeneration which, in some respects at least, differs from colloid 
degeneration. The hyaline substance differs from the colloid material in 
that it can be stained in acid fuchsin and eosin and resists water, alcohol, 
acids, and ammonia; and from amyloid as it does not react to iodine. 

Hyaline degeneration affects different organs and epithelial cells as well 
as connective tissue. Hyaline masses and thrombi were found by Manasse in 
the vessels of the brain in acute infectious diseases. Transformation of 
striated muscle-fibres into a fragile homogeneous shining substance anal- 
ogous to colloid masses occurs quite frequently. Zenker described this 
change first in 1864, and called attention to its constant occurrence in ab- 
dominal typhus. The lower ends of the abdominal recti and the adductors 
are most frequently affected, and it is here where the degeneration is most 
extensive. In many of the fibres the degeneration is most extensive, in 
others it is localized. The striations disappear entirely and the fibre is 
transformed into a structureless mass interspersed with a granular detritus, 
and is permanently destroyed. Zenker describes this change as a peculiar 



88 PEINCIPLES OF SURGERY. 

form of waxy degeneration. The same change has been also found in other 
acute febrile affections and it has been suggested that the degeneration 
might be the result of rupture of the muscle-fibres. Maier and Perls have 
seen colloid degeneration of the muscular fibres of the stomach and intes- 
tinal canal. 

AMYLOID DEGENERATION. 

Under the term of corpora amylacea and amyloid substance we include 
substances which, like the colloid material, have an homogeneous, faintly- 
shining appearance and which likewise resist chemical reagents, but which 
differ from the products of degeneration already described by its peculiar 
behavior toward iodine and some of the stains. Like starch, the amyloid 
substance is stained a beautiful blue or brown color on the addition of iodine. 
If the substance is stained brown the color is converted into greenish-blue 
color if sulphuric acid or chloride of zinc is added. In aged men amyloid 
granules are found in the prostate which react to iodine specifically. These 
minute round bodies present a concentric structure, in the centre of which 
occasionally a detritus of cells is found. Their consistence is variable, but 
they are always brittle. If exposed to iodine, some of them stain a deep 
blue in a few minutes, others bluish-green or brown, while others do not 
stain at all, showing that the reaction to iodine is influenced by inorganic 
constituents and modified albumen. In other organs smaller granules of a 
similar structure and composition are found; a constant location for these 
bodies is the ependyma of the ventricles of the brain and the acoustic 
nerve and in those pathological conditions of the central nervous system 
in which increase of connective tissue is followed by a corresponding increase 
of the parenchyma. These granules are paler than the myelin drops from 
which they are probably formed. Concentrated sulphuric acid increases 
the staining properties of iodine. Amyloid bodies are frequently found 
in the lungs, also, especially in hemorrhagic infarcts. Similar bodies are 
sometimes found in cartilage, especially in the intervertebral cartilages 
in a state of inflammation, and occasionally they are seen in diverse other 
tissues, such as cicatrices of the skin, phlebolites, and tumors. While 
the instances mentioned above represent a localized form of degeneration 
and without much pathological importance, there is a diffuse process 
which is known as amyloid degeneration of the tissues that appears 
simultaneously in different organs, accompanied by anaemia and hydropic 
conditions: a frequent cause of fatal marasmus. This degeneration mani- 
fests itself under the microscope in the form of swelling of different tissues, 
especially of the vessel-walls, and presents itself in the form of shining, 
vitreous, homogeneous masses, which, on the addition of iodine, are stained 
brown, which is changed into a greenish blue or a pure blue or violet if 



AMYLOID DEGENERATION. 89 

acids are added. Spleen, kidneys, liver, and lymphatic glands are the organs 
most frequently affected, and the change in them takes place in a definite 
part. In the spleen amyloid degeneration takes place in two distinct forms. 
In the so-called waxy spleen the organ is much enlarged, firm, inelastic, 
and somewhat doughy. The cut surface appears uniformly brownish red, 
shiny, unusually transparent, resembling smoked ham. Iodine stains the 
surface only somewhat deeper, but uniform, so that the change is not very 
apparent. Microscopical examination shows that the capillary spaces are 
surrounded by a narrow zone of a clear, homogeneous substance to which 
the normal or endothelial cells which have undergone fatty degeneration 
are attached. In the other form of amyloid degeneration of the spleen — 
the so-called sago spleen — the organ is softer and on section only the fol- 



i 



,-* * 



• i t « * * B 

®* • • 

« .,- # « ^ m 



Fig. 57.— Amyloid Degeneration of the Kidney Involving the Glomeruli and the Capil- 
laries of the Cortex. The Amyloid Material has been Stained Brown with Iodine. Double 
knife section. From a case of chronic pulmonary tuberculosis. X 75. A, capillaries 
showing amyloid degeneration. B, glomerulus showing amyloid degeneration. G, large 
vessel showing amyloid degeneration. 

licles present the characteristic changes in the form of sago-like structures, 
and only these react to iodine, and in them the blood-vessels appear as yel- 
low dots or stripes. In the amyloid kidney the glomeruli are enlarged and 
pale and on the addition of iodine become conspicuous by their brown color; 
very often the vasa recta of the pyramids are also found much degenerated 
and react intensely to the iodine stain. In the liver the amyloid degenera- 
tion begins and is most marked in the centre of the acini. 

The villi of the intestinal canal are frequently affected by amyloid de- 
generation, while the mucous membrane over Peyer's patches remains intact. 
In the suprarenal capsule and lymphatic glands the cortical layers of the 
parenchyma are principally affected and exhibit in the most marked manner 
the reaction to iodine. Examination of different organs which have under- 



90 PRINCIPLES OF SURGERY. 

gone amyloid degeneration have shown that different tissue-elements fur- 
nish the amyloid substance. Most frequently the walls of the small blood- 
vessels are primarily affected, and in these the change is first observed in 
the media, which is transformed into a structureless glassy mass, and the 
thickening of the walls thus caused diminishes the lumen of the affected 
vessels, which accounts for the anaemia so constantly found in amyloid or- 
gans. That the parenchyma-cells can undergo amyloid degeneration can 
be best seen in the amyloid follicles of the spleen and the acini of the amy- 
loid liv^er. Diffuse amyloid degeneration of different organs is most fre- 
quently observed as a remote result of prolonged suppuration following often 
tuberculosis of bones and joints and long-standing empyema and old cases 
of syphilis. It is more than probable that the toxins of the different kinds 
of pyogenic microbes play an important role in the etiology of diffuse amy- 
loid degeneration, which appears simultaneously or in more or less rapid 
succession in different organs in the course of chronic suppurative processes. 
The different forms of degeneration which have been described are of 
special interest to the surgeon, as he is often in a position to prevent such 
changes, and in the presence of some of them he recognizes the necessity of 
abstaining from performing major operations unless called for by emergen- 
cies which leave no other alternative. Among these special mention must 
be made of diffuse amyloid degeneration and fatty degeneration of the large 
blood-vessels, with and without calcification. Timely resumption of func- 
tion of diseased parts or organs, massage, and electricity are best calculated 
to prevent further degeneration and restore normal nutrition in the localized 
forms of degeneration, more especially fatty degeneration, the consequence 
of prolonged inactivity. 



CHAPTER IV. 

Inflammation. 

The subject of inflammation is one of deep interest both to the student 
and practitioner, as it initiates the former into the field of general and special 
pathology, and the latter meets with it daily in some form in his practice. 
We have already set apart from inflammation those numerous processes by 
which injuries or defects are repaired without destruction of any of the 
new tissue-elements which have been described in the first chapter under 
the head of "Regeneration." From a scientific and practical stand-point, 
it is exceedingly important to draw a distinct line between the series of 
tissue-changes which attend regenerative processes, uncomplicated by the 
action of pathogenic bacteria, and true inflammation, which is always caused 
by the presence of one or more hinds of pathogenic microbes. As compared 
with true inflammation, it has been customary for quite a number of years 
to speak of regeneration as a plastic or regenerative, inflammatory process; 
but the term inflammation in the future should be limited to the series of 
histological changes which ensue in the living body from the presence and 
action of specific microorganisms, while the word regeneration should be 
used to designate the histological changes which take place in tissues which 
have been primarily in an aseptic condition or have been rendered so after 
the inflammation has subsided. From this it will be seen that the study of 
inflammation is intimately and inseparably associated with a consideration 
of the new science of bacteriology. For most forms of inflammation the 
presence of a specific microorganism has been demonstrated, and its etio- 
logical relationship established by cultivation and inoculation experiments; 
and in the few inflammatory diseases where no such positive proofs can be 
furnished we have, from analogy and circumstantial evidence, reason to 
suspect the presence of undiscovered microbes. Inflammation, in the widest 
and most comprehensive meaning of the word, should be made to embrace 
pathological conditions which are caused by the action of pathogenic mi- 
crobes or their toxins upon the histological elements of the blood and the 
fixed tissue-cells. A correct definition of inflammation, which should em- 
body the etiological, anatomical, and pathological characteristics of the dis- 
ease from our present knowledge of the subject, cannot be given, as many 
important points connected with the complicated processes await explana- 
tion by future investigation. Sanderson defines inflammation as u the suc- 
cession of changes which occur in a living tissue when it is injured, provided 
that the injury is not of such a degree as at once to destroy its structure and 

(91) 



92 PRINCIPLES OF SUEGERY. 

vitality." As we have restricted the term inflammation to the succession of 
changes which occur in a living tissue from the action of pathogenic microbes 
or their toxins, this definition would cover processes which, for reasons 
already given, we have considered as instances of tissue-proliferation un- 
attended by any of the characteristic features of inflammation. J. Bland 
Sutton uses the term inflammation in a more restricted sense in coining the 
following definition: "It is the method by which an organism attempts to 
render inert noxious elements introduced from without or arising within it" 
As nothing is said of the method, the most important part of the definition, 
it certainly cannot be said to cover the whole ground. The conception of 
the true nature of inflammation for the present, at least, must remain 
symptomatic. As a rule, inflammation subsides as soon as the primary 
cause has disappeared or has been rendered inactive, as is well shown by 
the spontaneous disappearance of febrile disturbances in the general in- 
fective diseases, and the subsequent rapid repair of the local lesions which 
characterize them. If an acute inflammation become chronic, either from 
a diminution of the quantitative or qualitative intensity of the primary 
cause, or from the tissues becoming accustomed to its action, it is sometimes 
difficult to tell whether the primary cause has disappeared or has ceased 
to act, or whether it is still present and active. In chronic inflammation the 
most reliable indications of the presence and potency of the primary bac- 
terial cause are acute exacerbations, as chronic inflammation only consists 
of a series of acute inflammatory processes which repeat themselves at longer 
or shorter intervals. The differences between an acute and chronic inflam- 
mation are not in kind, but in degree. The complicated processes which 
characterize inflammation can be studied most profitably by considering 
separately and conjointly the symptoms to which they give rise, which Galen 
enumerated as color, rubor, dolor, et tumor, to which may now be added the 
functio Icssa of modern authors. The study of the objective and subjective 
manifestations of inflammation should be preceded by a short description 
of 

THE HISTOLOGICAL ELEMENTS WHICH ARE DIRECTLY CONCERNED IN 
THE INFLAMMATORY PROCESS. 

In a very recent article, the veteran pathologist, Virchow, makes the 
statement that inflammation is not a uniform process with constant char- 
acteristics. He recognizes and describes four distinct varieties, viz.: 1. 
Exudative. 2. Infiltrative. 3. Parenchymatous. 4. Proliferative. Each 
of these furnishes different products. Inflammatory hyperemia is a prime 
factor in exudative and infiltrative inflammations, while it takes a secondary 
part in metamorphosing and the proliferating forms. In the study of the 
complicated processes which characterize inflammation, it is important to 



HISTOLOGICAL KI.HMKNTS IK THE INFLAMMATORY PltOCESS. 



93 



study the part which the different tissues take in the morbid process. The 
most important structures, and which are always concerned in inflammation 
of all types and varieties, are the 

Capillary Vessels. — The most important histological changes in inflam- 
mation, acute or chronic, transpire within, and in the immediate vicinity 
of, capillary vessels. The smallest arteries and veins, the vessels on either 
side of the capillaries, undergo changes, and the disturbance of circulation 
within them constitutes a part of the picture of inflammation, but it is in 
the capillaries that the most serious disturbances occur; it is here where 




Fig. 58. — Capillary Vessels of the Frog's Mesentery, Stained with Nitrate of Silver 
only; the Wall of the Vessel is Viewed from the Surface, and is Seen to Consist of 
Elongated Endothelial Cells, Marked by their Outlines only; the Nucleus of the Indi- 
vidual Cells is not Shown. (Klein.) 

the noxce are brought in closest contact with the paravascular tissues, and 
it is here where the inflammatory exudation and transudation take place. 
The capillaries are minute vessels, or rather channels, which connect the 
arteries and veins, the walls of which are composed of a thin, elastic, endo- 
thelial membrane; that is, a single layer of nucleated cells held together 
by an amorphous cement-substance. In silver-stained specimens the cement- 
substance appears as dark lines which outline the boundaries of the cells. 
The shape of the cells is more or less elongated, with pointed extremi- 
ties, and their outline smooth or sinuous. The nuclei of these cells are oval, 
situated either about the middle of the cell or near one extremity. The 



94 PRINCIPLES OF SURGERY. 

nucleus contains within a well-defined membrane a net-work of chromatin 
threads, but no nucleolus. When the capillaries undergo alteration and dis- 
tension, as in inflammation, the cement-substance yields in many places; 
in consequence of this minute openings appear, called by Arnold stigmata, 
which become gradually enlarged into stomata. Winiwarter found that by 
injecting inflamed capillaries the contents of the vessel escaped through 
these openings. Through these openings emigration of leucocytes takes 
place, and when the inflammation is very intense the red corpuscles escape: 
a process which Strieker has named diapedesis. If the capillary vessels, 
through which emigration has been going on, be stained with nitrate of 
silver, it is seen that the emigration is limited to the interstitial cement- 
substance of the endothelial wall. (Purves.) 

Klein has shown that the walls of all capillary vessels in the adult state 
form a direct connection with the process of the connective-tissue corpuscles 
of the surrounding tissue: a matter of great interest in studying the rela- 




Fig. 59. — Leucocyte, showing Reticulum of Protoplasmic Strings. (Klein.) 

tionship between the capillary vessels and the surrounding connective-tissue 
spaces. 

Blood-corpuscles. — The blood-corpuscles frequently serve as carriers of 
the microbic cause of the inflammation; they block the lumen of inflamed 
capillary vessels, partially or completely, and constitute the histological ele- 
ments of the primary exudation. The element of the blood which is more 
intimately associated with the histology of inflammation is the 

1. Leucocyte, or White Blood-corpuscle. — This is a nucleated, spherical, 
transparent mass of protoplasm, without a limiting membrane or envelope. 
Heitzmann made the discovery that it is composed of a reticulum of proto- 
plasmic strings, with a hyaline substance in the meshes. 

The nucleus shows a similar structure, and its net-work is continuous 
with that of the cell-body. Strieker and Klein, as well as a number of other 
histologists, have adopted Heitzmann's views in reference to the minute 
anatomy of the leucocyte. The reticulated structure is well shown by stain- 
ing with chloride of gold, which stains the protoplasmic strings, but not the 



HISTOLOGICAL ELEMENTS IN THE INFLAMMATORY PROCESS. 95 

interstitial substance. The leucocyte is endowed with intrinsic power of 
locomotion, — amoeboid movements, — a function which is performed by the 
reticulum. Wharton Jones discovered motion of protoplasm in leucocytes 
of human blood as early as 1846. In 1862 Haeckel showed that the white 
blood-corpuscles absorb pigment-granules: a process which can only take 
place by amoeboid movements, which by change of form of cell bring the 
foreign material into its interior by inclusion. These observations enabled 
Cohnheim to demonstrate later that the white blood-corpuscles found in the 
vascular spaces of the cornea were derived from the blood; in other words, 
to establish the fact of emigration of leucocytes through the inflamed wall 
of capillaries. The amoeboid movements of the colorless corpuscles can be 
well observed for hours in the moist chamber on the warm stage. 

The movements of a leucocyte are peculiar. The first effort consists 





Fig. 60. — Change of Forms of a Moving Leucocyte by Amoeboid Movements. (Klein.) 

of a protrusion of a hyaline film. This is withdrawn and another is pro- 
truded; in the next moment this is diminished to a very minute process, 
whereas, on the opposite side, a new, broad process appears. After this the 
corpuscle is seen to throw out processes of various length and thickness, and 
thus to alter its shape in a considerable manner. By virtue of the amoeboid 
movement of leucocytes they move from place to place independently of 
the blood- or plasma- current. This independent locomotion enables them 
to pass through the small opening in the wall of inflamed capillaries, and, 
after they have reached the paravascular tissues, to travel along connective- 
tissue spaces until arrested by some mechanical obstruction. If pigment- 
material, in a finely-divided state, is mixed with blood, either before or after 
withdrawing it from the vessels, the projections thrown out by the leuco- 
cytes inclose the particles brought in contact with it, and the granules reach 



96 PRINCIPLES OF SURGERY. 

in this manner the interior of the leucocytes, and are variously distributed 
according to the shape and movements of the protoplasm. Microbes reach 
the interior of the leucocytes in the same manner. In cases of intravascular 
infection the emigration corpuscles convey with them the microbes through 
the wall of inflamed capillaries into the tissues surrounding them. 

Grawitz certainly underestimates the part the leucocytes perform in 
inflammatory processes, as he denies, in toto, the leucocytic nature. — that is, 
their derivation from the blood in exudates, — claiming there is no proof in 
support of Cohnheinrs teachings. He does not consider the proliferation 
theory of Virchow alone in cell-production. His own view, that cells arise 
from the intercellular substance and from cell-particles, is emphasized, and 
is called "Sclilummerzellen theory. " He combats the teachings of Senftleben 
and Leber, who claim that cells formed in a supposed dead cornea introduced 
into tissues as immigrated cells. He claimed the corneal tissue was not dead, 
because: (1) cornea was removed from animal several days; (2) heating to 
80° C. for one-quarter hour; (3) desiccation of tissue: all of which are in- 
sufficient, in his opinion, to destroy the tissue. If such tissue is introduced 
into the lymph-sac of frogs, it is invaded by wandering cells, which are not 
immigrated cells, but are derived from the corneal tissue itself. In dead 
corneal tissue (heating to 52° C. or immersion in sublimate solution), no 
wandering cells when inserted in a frog's lymph-sac. Ingenious as these 
experiments may appear, they do not militate against the theory that leu- 
cocytes are constantly found in inflammatory tissue, and perhaps the most 
important proof of the important part they take is the marked leucocytosis 
which is always found during all acute inflammatory affections. 

2. Red Blood-corpuscle. — The colored blood-corpuscle serves less fre- 
quently as a carrier of microbes than the leucocyte, as it does not possess as 
active amoeboid movements. For the same reason it is not found so con- 
stantly as a component part of the inflammatory exudation, as its transit 
through the capillary wall is a more passive process, and is accomplished 
principally by the vis a tergo in case the stomata are sufficiently large to 
permit its passage. Leonard has recently demonstrated the amoeboid move- 
ments of the red corpuscles by instantaneous microphotography. The move- 
ments extended over half an hour upon the warm stage, and the pictures 
obtained are well shown in Fig. 61. The presence of numerous colored cor- 
puscles in the exudation is an indication of great acuity and intensity of the 
inflammation: conditions causing serious and extensive alterations of the 
capillary wall. The escape of whole blood through a capillary vessel greatly 
damaged by the cause of the inflammation is called rhexis. 

3. Third Corpuscle. — A third cellular element in the blood, the third 
corpuscle, was discovered by Max Schultze, in 1865. He described it as a 
small, colorless sphere, or granule. Elaborate descriptions of this corpus- 



HISTOLOGICAL ELEMENTS IX THE INFLAMMATORY PRO- BBS. 






cle wore given by Hayem. in 1878, and Bizzozero, in 1882. Hayem, from 
his observations, believed that these minute structures represented young 
colored blood-corpuscles, and hence named them haematoblasts. Bizzozero 
entered his protest against this theory and called them blood-plates (Blut- 
pldtMien). Under the microscope they appear as minute, faintly-colored 
blood-corpuscles. They seem to possess a little stroma like the red blood- 
corpuscles, but contain no nucleus and are devoid of any cell-membrane. 
T\ hat appears as a nucleus is, according to Hayem, an optical defect. 

Hayem estimates that they are forty times more numerous in man than 
the leucocytes, and twenty times more abundant than the colored corpuscles. 
As there has been no positive proof furnished that the third corpuscle is an 
embryonal red blood-corpuscle, and as it has been shown that blood-corpus- 
cles are produced from the fixed cells of blood-producing organs, as, for in- 
stance, the spleen and medullary tissue, it is advisable not to apply to it the 




Amceboid Morements of Red Blood-corpuscles. (After Leonard.) 



term haematoblasts, but to distinguish it from the remaining two morpho- 
logical elements of the blood numerically by calling it the third corpuscle. 
Under a higher power the third corpuscle can be readily recognized in the 
blood-stream of capillary vessels in the mesentery or web of a frog. In blood 
withdrawn from a vessel it is destroyed as soon as coagulation sets in; hence 
it disappears almost immediately after it leaves the blood-vessel. In order 
to study it outside of the body, means must be employed to prevent coagula- 
tion, which can be done by mixing the blood with the following solution, 
recommended by Hayem: — 

Distilled water 200.00 cubic centimetres. 

Sodic chloride 1.00 gramme. 

Sodic sulphate 5.00 grammes. 

Mercury bichloride 0.50 gramme. 

From a needle-puncture the blood is allowed to mix with the solution 
in the proportion of about 1 to 20 up to 1 to 100. In this mixture the third 



98 



PRINCIPLES OF SURGERY. 



corpuscle will retain its shape and size for twelve to twenty-four hours. The 
third corpuscle is a fibrin-producing structure, and, as such, it takes an active 
part in the formation and growth of intravascular blood-clots. The white 
mural thrombus, produced intra vitam, is composed almost exclusively of 
this element of the blood. If, from a trauma or disease, the endothelial 
lining of a blood-vessel is injured and the smooth surface becomes uneven, 
the third corpuscles, floating in the peripheral portion of the axial current, 




/ 0^^°^) O 0^% 0\0 ^^ W Wo 




^"woOgC! 



C\<7 Q> 









Fig. 62. — 1. Third corpuscle. A, natural appearance when seen on surface and on 
edge; B, C, C, D, and E, appearance presented by them during coagulation. 2. Shows 
the little heaps of granules formed by them after coagulation (Hayem). 3. A small blood- 
vessel as stasis is approaching. A, third corpuscles in periphery of stream; B, colored 
blood-corpuscles; C, leucocyte. (Eberth and Schimmelbusch.) 

come in contact with projecting points, and are arrested and become attached 
to the vessel-wall, layer after layer is added, and in this manner the mural 
thrombus is formed. On the surface of recent wounds they appear in large 
numbers, lose their fibrin-ferment, and give rise to the formation of fibrin, 
which acts both as an haemostatic and temporary cement-substance. In in- 
flammation the third corpuscle escapes through the capillary wall in the 
same manner as the red corpuscles, but, on account of its smaller size, its 
peripheral location in the blood-stream, and its greater abundance, it is 
numerically more abundant in the inflammatory exudation. The fibrin in 
inflamed tissues is undoubtedly derived largely from this source. 

4. Fixed Tissue-cells. — The fixed tissue-cells behave differently in the 
inflamed part, according to the intensity and nature of the primary mi- 



HISTOLOGICAL ELEMENTS IN THE 1 NFI.A M M ATOI! Y PROCESS. 99 

crobie cause. The microbes, or their ptomaines, may possess such intense 
local toxic properties as to destroy their vitality directly, when the inflam- 
mation results in necrosis, as in the case in the centre of an ordinary furuncle 
and on a larger scale in cases of progressive phlegmonous inflammation. 
The fixed tissue-cells may be destroyed by starvation, by the primary inflam- 
matory exudation being so abundant as to obstruct the circulation in the 
inflamed part. If the cause of the inflammation is less intense, as is the 
case in chronic inflammation, the fixed tissue-cells are brought in direct 
contact with the microbes which produced the inflammation, and active 
tissue-proliferation is the result, and this furnishes the bulk of the inflam- 
matory product. The histological structure of tubercle furnishes a good 
illustration of the part taken by the fixed tissue-cells in chronic inflamma- 
tion. In chronic suppurative inflammation the fixed tissue-cells are first 
transformed into embryonal tissue, and, as the protoplasm of the new cells 
is destroyed by the ptomaines of pus-microbes, they are converted into pus- 
corpuscles. A passive role in the inflammatory process was assigned to the 
fixed tissue-cells by Boerhaave, who regarded stasis as the essential feature 
of inflammation: by Andral, who believed that hyperemia was the charac- 
teristic pathological condition in an inflamed part; and by Rokitansky, who 
taught that exudation constituted the most important element in all in- 
flammatory lesions. Virchow located the primary seat of inflammation in 
the fixed tissue-cells, and asserted that nutritive or formative irritation oc- 
curred in them independently of vessels or nerves. He maintained that, the 
more the cells were disposed to take up nutritive material, the greater the 
danger that they themselves would be destroyed. Eemaining faithful to 
the doctrine that inflammation is only caused by the presence and action of 
a specific microbic cause, we shall find that, the more acute the process, the 
less the probability that the fixed tissue-cells take an active part, and that, 
the more chronic the inflammation, the greater the amount of the new 
material that has been derived from the fixed tissue-cells, and the smaller 
the quantity of vascular exudation. 

5. Plasma-cells and Mast-cells. — An occasional cellular product of in- 
flammation are the plasma- and mast- cells. Ivannoics distinguishes two 
distinct morphological forms of plasma-cells: (1) a round or oval cell, which 
may send out short processes, the nucleus being deeply stained and present- 
ing coarse parietal granules; and (2) an oval, spindle-shaped cell, with 
numerous processes and not unlike connective-tissue cells; the nucleus is 
long and the chromatin granules more lightly stained than in the first. 
He believes the first are derived from polymorphonuclear leucocytes and 
lymphocytes, and the second from connective-tissue cells, and claims that 
this cell can only form connective tissue. Gherardini believes that the mast- 
cells are identical with plasma-cells and that they originate from leucocytes 

LofC. 



100 PRINCIPLES OF SURGERY. 

and which, during their phagocytic activity, retain some of the products of 
cell-disintegration. The differences between the mast-cell and plasma-cell 
are simply different stages in the development of the same cell. 

SYMPTOMS OF INFLAMMATION. 

The structural changes caused by inflammation give rise to a charac- 
teristic complexus of symptoms, — pain, redness, swelling, heat, and suspen- 
sion — diminution, increase, or perversion of function. These symptoms vary 
in intensity, according to the nature of the primary cause and the anatomical 
structure and location of the tissues affected. One or more of the symptoms 
enumerated may be absent, when the existence of inflammation must be 
ascertained by a more careful study of those presented. In acute inflamma- 
tion the symptoms appear in rapid succession or almost simultaneously, while 
in the chronic form they come on slowty, often almost insidiously, and fre- 
quently one or more are wanting, even when the disease is far advanced. 
The number and intensity of the individual symptoms var}^ not only accord- 
ing to the virulence of the primary microbic cause, but are also modified 
by the resisting capacity of the individual and the tissues affected. We speak 
of a complete or partial immunity to certain microbic diseases, and of a gen- 
eral or local, hereditary or acquired, disposition. For diagnostic purposes 
the symptoms must be studied individually and collectively, and with spe- 
cial reference to their etiology and the location and structure of the inflamed 
tissues or organ. 

(a) Pain. — Pain is one of the most variable symptoms of inflammation. 
It is caused by traction or pressure to which sensitive nerve-filaments are 
subjected in the inflamed tissues, and probably, also, in some instances, at 
least, by extension of the inflammatory process to the structure of the nerves 
themselves. Some patients are more sensitive to pain than others. The 
same extent and degree of inflammation of the same part giving rise to sen- 
sation of discomfort in a torpid person may cause excruciating pain in pa- 
tients with a nervous temperament. As the degree of pain will depend 
largely upon the number of sensitive nerves present in the inflamed area and 
the amount of exudation, w T e would naturally expect to find pain a prominent 
symptom in inflammations of unyielding tissue freely supplied by sensitive 
nerves. This, as a rule, is the case. Pain is a distressing symptom in cases 
of phlegmonous inflammation of the fascia and tendon-sheaths of the fingers 
and palm of the hand. Pain is the most conspicuous symptom in periostitis 
and inflammation of the serous membranes. Wherever the inflammatory 
exudation appears rapidly in parts freely supplied with sensitive nerves, pain 
from tension appears as one of the foremost symptoms, and continues with- 
out intermission until tension is relieved. In acute suppurative osteomye- 
litis intense pain is present from the very commencement of the disease, and 



SYMPTOMS OF INFLAMMATION. 101 

continues unabated until tension is removed by operative procedures, or by 
escape of inflammatory product, through some defect in the bone, into the 
more yielding paraperiosteal tissues. The pain is throbbing, sometimes syn- 
chronously with the pulse, in acute circumscribed phlegmonous inflamma- 
tion. It is sharp and lancinating in inflammation of serous membranes. It 
is described as a burning sensation in inflammation of the skin. The "pain 
is of a dull, aching, boring character in deep-seated inflammation, especially 
in the interior of bone. Xocturnal exacerbation of pain is a common occur- 
rence, and seldom absent in painful syphilitic affections. The pain is not 
always referred by the patient to the seat of inflammation, as in the early 
stages of coxitis it is not in the hip, but over the inner aspect of the knee, 
and in inflammatory affections of the nerves the pain radiates along the 
peripheral branches, and is usually felt most severely some distance from 
the seat of the disease, at points supplied by the peripheral branches. In 
ascertaining the existence and exact location of a deep-seated inflammation, 
tenderness is a more valuable symptom than spontaneous pain. Tenderness 
is the pain elicited by pressure. If the inflamed part is tender on pressure 
and accessible to palpation, the area of tenderness will correspond to the 
extent of the inflammation. During the beginning of an attack of phleg- 
monous inflammation the surgeon is able to locate the affection accurately 
by searching for the point where the tenderness is most acute, and the same 
symptom will indicate to him, earlier than any other, the direction in which 
the process is extending. In periostitis the area of tenderness will show 
whether the inflammation is circumscribed or diffuse. The existence of cir- 
cumscribed points of tenderness about the epiphyses of the long bones is 
almost a certain indication of central osseous tuberculosis, and, at the same 
time, furnishes a reliable guide in their early operative treatment. Firm 
pressure relieves pain in nervous hysterical patients, while it aggravates it 
when it is caused by inflammation. On the other hand, superficial pressure 
made with the tips of the fingers increases the suffering in parts the seat of 
functional disturbance, while it does not materially affect the pain resulting 
from inflammatory lesions. 

(b) Redness. — The composition of normal blood is admirably adapted 
for the passage of this fluid through capillary vessels. As long as the relation 
of corpuscular elements to the blood-plasma remains normal, and the intima 
of the blood-vessels remains intact, and the vis a tergo is adequate, there is 
no tendency to capillary obstruction. If the capillary circulation in the 
mesentery of a frog is examined under a microscope, there is no difficulty in 
distinguishing two currents: the axial and peripheral. The axial, or central, 
current is rapid, and conveys the red corpuscles, which have the same spe- 
cific gravity as the blood-plasma, while the peripheral current between the 
axial and vessel-wall is considerably slower, and in this current the colorless 



102 PKINCIPLES OF SURGERY. 

corpuscles are conveyed, their rotating motion being due to their coming in 
contact with the wall of the vessel. D. J. Hamilton has shown, by numerous 
experiments, that, in fluids holding in suspension solid particles passing 
through capillary tubes, the heaviest particles are carried along the central 
current, while those specifically lighter than the fluid seek the peripheral 
current. The leucocytes are specifically lighter than the fluid in which they 
are contained; hence they are forced into the space between the axial cur- 
rent and the vessel-wall (Fig. 62, C). The third corpuscle, probably for the 
same reasons, moves also in the peripheral stream. The colorless corpuscles 
accumulate more in the peripheral stream when the current is feeble than 
when it is rapid. This fact is of great importance in the study of the altered 
circulation when the capillary vessels are in a state of inflammation. The 
accumulation of colorless corpuscles in the peripheral stream in inflamed 
capillary vessels, according to Thoma, Eberth, and Schimmelbusch, is owed 
to the slowness of the current, which, although insufficient to propel the 
specifically light, colorless corpuscles, is still competent to force onward the 
less-resisting and specifically heavier-colored corpuscles. 

Eberth and Schimmelbusch state that in the vessels of a warm-blooded 
animal four kinds of stream are noticed, in accordance with its velocity: (1) 
the normal stream, in which the axial current and peripheral zone are readily 
recognizable; (2) a slow stream, in which the leucocytes accumulate in the 
periphery; (3) a still slower stream, in which the third corpuscles also leave 
the axis and accumulate in the periphery, and in which, these observers assert, 
the leucocytes become less numerous; and (4) a stream so slow as to ap- 
proach stagnation, in which all the elements of the blood are indiscriminately 
mixed. From the above it can be seen that all general and local conditions 
which tend to diminish the velocity of the blood-current in the capillary 
vessels are productive of accumulation of the colorless corpuscles and of 
the third corpuscles in the peripheral stream: a condition which greatly ag- 
gravates the existing local impediments to capillary circulation, and when 
well advanced, by encroaching more and more upon the central stream, will 
result in complete stasis. Temporary hyperemia of a part or organ is a fre- 
quent occurrence, and is often the result of abnormal innervation. The in- 
fluences of the nervous system — particularly of the sympathetic nerves — 
over the circulation are familiar to every student of physiology. Temporary 
hyperemias and anaemias of certain parts or organs of the bod}? - — the result 
of abnormal innervation of the vasodilators or vasoconstrictors — frequently 
bring about vascular changes which predispose to the localization of the 
essential microbic cause of inflammation. Injury to nerves, mental excite- 
ment or depression, and exposure to cold are potent factors in the produc- 
tion of temporary vascular disturbances. Two forms of active hyperemia, 
due to faultv innervation, must be recognized. When caused by a paralysis 



SYMPTOMS OF INFLAMMATION. 103 

of the vasoconstrictors it is described as hyperemia of paralysis. A classical 
demonstration of this form of hyperemia was furnished by Claude Bernard 
by his experiment, which consisted of division of the cervical sympathetic 
in the rabbit, which was invariably followed by marked hyperemia and dila- 
tation of the blood-vessels in the ear on the corresponding side. When the 
vasodilators are irritated by mechanical or electrical stimulation the arte- 
rioles dilate and the part presided over by the affected nerve becomes hyper- 
emia, and the condition of the circulation is known as hyperemia of irrita- 
tion. A good illustration of this form of hyperemia can be produced by 
stimulation of the chorda-tympani nerve, which, as was shown first by 
Claude Bernard, always produces dilatation of the vessels in the submaxillary 
gland. Passive hyperemia is caused by mechanical conditions which inter- 
fere with the return of venous blood. Ligation of a vein furnishes the sim- 
plest variety of this form of venous congestion. Thrombophlebitis; varicose 
veins; pressure upon veins caused by tumors, the pregnant uterus, and in- 
flammatory products; and pressure caused by a dislocation or fractured 
bone, as well as organic disease of the heart and lungs and cirrhosis of the 
liver, afford familiar instances of the more common mechanical interfer- 
ences with the venous circulation. The chronic or frequently-recurring hy- 
peremia in a part usually results in increased nutritive activity of the tissues 
and hyperplasia in the absence of infection. This effect of chronic hyper- 
emia has been made use of in practice by producing the condition artificially 
in the treatment of tubercular affections accessible to this kind of treatment 
(Bier). Eedness as a symptom of inflammation signifies an excess of blood 
in the part, and the terms used to indicate its existence are hyperemia and 
congestion, while complete arrest of the capillary circulation is expressed by 
the word stasis. Accurately speaking, hyperemia should be used to designate 
that condition of the circulation where the part not only contains an in- 
creased amount of blood, but where an increased amount of blood flows to 
and returns from the part: an exalted physiological process; while the word 
congestion literally means only an accumulation of blood in a part: a con- 
dition owed to some form of local or distant mechanical obstruction. The 
conditions giving rise to redness, hyperemia, congestion, and stasis should 
not be studied only from descriptions, but in order 10 be understood they 
should be seen. This can be readily done by producing artificially an in- 
flammation in a transparent part of some lower animal, preferably the frog, 
and studying the circulation in the inflamed part step by step under the mi- 
croscope. For this purpose experimenters have usually selected the frog's web, 
mesentery, tongue, lung, and bladder, and the tadpole's tail. For general use 
the frog's web should be selected, as the preparations for this experiment are 
very simple. Inflammation is provoked by cauterizing the web with a needle 
heated to a red heat, or by applying with a small plug of cotton some power- 



104 



PRINCIPLES OP SURGERY. 



ful irritant, as ammonia, tincture of cantharides, or croton-oil, or by touch- 
ing the surface with a sharp stick of nitrate of silver. Hamilton gives the 
following directions for making the experiment: "Nothing more is neces- 
sary than a piece of tin or other soft metal, about 1 1 / 2 to 2 inches broad and 
about 6 to 8 inches long, or, what is better, a thin piece of hard wood of the 
same dimensions. At the end where the web is to be stretched it should not 
be so broad. From the narrow end of this a Y-shaped piece is cut out, over 
which the web is to be spread. The frog should first be curarized, as this 
does not interfere with the circulation, provided that the solution employed 




Fig. 63. — Normal Circulation in Frog's Web. A, artery; B, vein; C, capillaries. 
Vessels covered by a net-work of polygonal epithelial cells of web, in which pigmented 
cells are not represented. (Landerer.) 



be not too strong. The V2000 °f a grain, in watery solution, injected under 
the skin, is sufficient. Chloral may be substituted. Caton recommends a 
solution of 4 grains to the drachm. As many minims should be injected 
subcutaneously as the frog is drachms in weight. The injection is made un- 
der the skin of the back with an ordinary hypodermic syringe. The animal 
is laid on the piece of metal or wood, and, the web being stretched over the 
cleft at the end, the toes are held by tying a piece of thin thread to them 
and fixing the ends into a fine slit cut in the metal or wood." The micro- 
scope is so arranged and adjusted that the field of observation will correspond 
to the point of irritation. A sufficiently high power is used so that the dif- 



SYMPTOMS OF INFLAMMATION. 



105 



ferent corpuscular elements in the capillary stream can be readily seen and 
recognized. In order to witness the different stages of the inflammatory 
process it is necessary to continue the observation for hours. 

Any one of the irritants mentioned applied to the frog's web will pro- 
duce in the capillaries over a limited area a series of changes which are always 
present in inflammation, and a description of them will represent what takes 
place in capillaries the seat of inflammatory processes of bacterial origin; 
almost simultaneously with the application of the irritant a momentary con- 
traction of the vessel occurs, caused by the stimulation of the vasocon- 
strictor nerves, which is followed by dilatation, with increased velocity of 




Fig. 64. — Capillaries of Frog's Web in a State of Hyperemia soon after Application of 
Irritant. A, artery; B, vein; C, capillaries. (Landerer.) 



the capillary current: a true hyperemia. The bright-red color of the hyper- 
aemic part at this stage, according to Eecklinghausen, is due to increase in 
the rapidity of the blood-current, but, as the color of the blood indicates a 
diminished expenditure of oxygen and a smaller quantity of carbon in the 
blood, increased velocity alone would not explain this change. Diminished 
alkalescence in the inflamed tissues may reduce the amount of oxygen used, 
as is the case in glands during active secretion, where Claude Bernard showed 
that defective oxygenation is always present. At this stage the corpuscular 
elements circulate in their respective streams, and the whole picture is one 
of increased physiological activity. Dilatation of the vessels follows con- 



106 PRINCIPLES OF SURGERY. 

traction so quickly that it would be difficult to explain it as a paralytic phe- 
nomenon. Its early outset and the rapidity with which it appears would 
point to a neurotic cause, traceable to the action of ganglia in the vessel- 
wall. It has not yet been satisfactorily explained whether this early dilata- 
tion of the vessel is due to vasomotor paralysis or irritation of the vaso- 
dilators, but it is more probable that it is caused by the vasodilators, 
while, later, paralysis from overdistension occurs. Division of the sym- 
pathetic in the neck brings about increased vascularity, but no inflam- 
mation. The difference between dilatation of an inflamed vessel and the 
dilatation following division of the sympathetic consists in alteration of the 
capillary wall, in the former instance produced by the action of the causes 



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Fig. 65. — Plasma-cells in Acute Interstitial Nephritis. (Low power.) 

which induced the inflammation, while in the latter the dilatation is a 
purely-nervous phenomenon, unattended by other pathological conditions 
of the vessel-wall. Disturbances of the circulation alone are not sufficient 
to bring about the local changes which are characteristic of inflammation; 
if the velocity of the blood-current is greatly diminished by purely mechan- 
ical or nervous causes, mural implantation of the white corpuscles may take 
place, but emigration does not occur on account of the absence of the essen- 
tial condition which gives rise to it: alteration of the capillary wall. 

Dilatation is first noticed in the smallest arteries, afterward in the veins 
and capillaries, and keeps increasing from fifteen minutes to two hours. 
The vessels often enlarge to double their normal calibre. During the stage 
of dilatation many of the capillaries which were small or contained but little 



SYMPTOMS OF [NFLAMMATION. 107 

blood become visible, which greatly adds to the turgidity and redness of the 
inflamed part. As long as the acceleration of the capillary current con- 
tinues, the different corpuscles move in their respective currents. The white 
corpuscles that are mingled with the colored are washed along with the latter 
in the central stream without finding their way into the slower side-current 
which propels the leucocytes and the third corpuscles. The leucocytes in 
the peripheral stream appear more numerous, and skip along by more rapid 
rotatory movements. At this time the circulation has reached its greatest 
speed, and the tissues present every appearance of well-marked hyperemia. 
In from fifteen minutes to two hours from the time the irritant was applied 
intravascular changes are noticed which are calculated to impede the capil- 
lary current. The first link in the chain of local causes which obstruct the 
capillary circulation consists of a crowded condition of the vessels from a 
greater accumulation of the different corpuscles, which is soon followed by 
a greater separation of the leucocytes from the central current and their 
greater accumulation in the peripheral stream, where they often become 
arranged in heaps and little masses. This change is first observed in the 
small veins, and somewhat later, and to a lesser extent, in the smallest 
arteries. Separation of the blood-corpuscles is the necessary outcome of 
slowing of the stream from greater accumulation. In the peripheral zone 
of leucocytes the next source of obstruction is created. Some of the colorless 
corpuscles become momentarily attached to the capillary wall, when they 
are again detached by the force of the current, or are rolled away by another 
leucocyte. As the process advances it appears as though the viscosity of the 
leucocytes was increasing constantly, as more and more of them become ad- 
herent, while fewer are again detached. The lumen of the vessel is narrowed 
more and more by mural implantation of the leucocytes. The small veins 
now assume an appearance as if the internal surface of their wall were paved 
with leucocytes, while in the capillaries a similar adhesion of the leucocytes 
to the wall is noticed. At this stage it often appears as though complete ob- 
struction would occur every moment, the capillary stream becoming com- 
pletely arrested for a moment, and the current may even move in an opposite 
direction, when the obstruction is again overcome and the current moves once 
more in the right direction. The smallest arteries exert themselves to the 
utmost to clear the way, and pulsations can be seen where, in a normal con- 
dition, they are absent. Hyperemia has now given way to congestion. An 
intravascular obstruction has given rise to accumulation of blood on the prox- 
imal side of the inflamed vessel. Increasing slowing of the current gives rise 
to greater accumulation of leucocytes, which become firmly adherent to the 
capillary wall, narrowing the vessel more and more until the space for 
the axial current becomes too small for the passage of the red corpuscles, 
when complete arrest of the circulation takes place. Congestion has resulted 



108 PRINCIPLES OF SURGERY. 

in stasis. As soon as complete stasis has taken place the colorless corpuscles 
become mixed with the red corpuscles which are forced into the mass of the 
white, while by amoeboid movements the latter wander toward the centre of 
the vessel and mix freely with those which were moving in the central cur- 
rent. The most advanced stages of vascular disturbance are, of course, 
noticed first where the irritant was applied; so that when complete stasis has 
taken place in the centre a zone of congestion surrounds this, while more 
distant vessels still present every indication of active hyperemia. Redness 
is most marked where hyperemia is extant; that is, in parts containing a 
maximum amount of arterial blood. As soon as congestion sets in, the blood- 
corpuscles, red and white, do no longer pass through the vessel with the same 
rapidity and number, and the redness gives way to a bluish tinge, which be- 
comes well marked and does not give way to pressure when complete stasis 





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'ig. 66.— Three Plasma-cells in 


Acute Interstitial Nephritis. (High power.) 



has occurred. The blood in the stagnated vessels, according to Paget, has 
little tendency to coagulate; hence the possibility of restitutio ad integrum 
of the circulation after subsidence of the acute symptoms. Complete stasis 
occurs first in such capillaries where the vis a tergo is greatly diminished by 
a circuitous route from an artery to a vein, and increases in the direction 
in which the blood-current is slowest. In warm-blooded animals the phe- 
nomena of inflammation do not differ materially from those observed in the 
frog's web, except as regards the presence and disposition of the third cor- 
puscles. According to Eberth and Schimmelbusch, in warm-blooded ani- 
mals the third corpuscles in the normal capillary circulation move along 
with the colored corpuscles in the axial current, and hence they maintain 
that they must be of nearly the same specific gravity. A few of the leuco- 
cytes, mixed with the colored corpuscles and the third corpuscles, are found 



SYMPTOMS OF INFLAMMATION. ] 09 

in the central stream, but the majority of them arc propelled by the periph- 
eral stream, which, according to those observers, is from ten to twenty times 
slower than the central or axial current. With the slowing of the stream 
from alteration of the capillary wall and subsequent intravascular conditions, 
separation of the corpuscles takes place in the same manner as has been de- 
scribed in the frog's web; the leucocytes and third corpuscles leave the 
central stream and accumulate in the slower peripheral zone of the capillary 
stream, where they give rise to a greater degree of slowing of the column 
of blood by the formation of intravascular obstruction, which, if sufficient 
in degree, finally arrests the central current, thus causing stasis. The in- 
flammatory process in warm-blooded animals can be studied advantageously 
in the artifically-inflamed omentum of young animals, especially the guinea- 
pig, as the omentum in these animals is exceedingly delicate and transparent. 
The animal is narcotized by injecting subcutaneously 3 grains of hydrate 
of chloral for a full-grown animal. As the animal, with the exception of 
the head, is to be kept immersed in a physiological solution of salt kept at a 
temperature of the body in a large vat with a glass bottom, it is wrapped 
in a sheet of gutta-percha tissue long enough to overlap the head, and 
made so as to inclose a funnel-like space through which it may breathe. An 
opening is made in the covering at a point corresponding to the abdominal 
incision, through which the omentum is withdrawn. The object-glass of 
the microscope is immersed in the solution, and the omentum laid over a 
slide without fastening it. The vat is made so that it will fit on to the stand 
of an ordinary microscope, so that the light can be readily adjusted. Two 
tubes, one to convey the salt solution into the vat and another to conduct it 
away, are attached at opposite sides. These can be connected with a vessel 
the temperature of which is kept constant by means of a thermostat and Bun- 
sen burner. 

(c) Swelling. — The primary swelling in inflammation is due to dila- 
tation of blood-vessels, and its degree will depend on the vascularity of the 
part inflamed. The more numerous the blood-vessels, the greater the swell- 
ing from this cause. As the inflamed blood-vessels will often dilate within 
two hours to double their normal calibre, the primary swelling in vascular 
organs in a state of acute inflammation will come on quickly, and will give 
rise to a not inconsiderable enlargement of the inflamed part. If during this 
stage of inflammation the tissues are incised, haemorrhage is profuse, and 
the emptying of turgid blood-vessels by this means has a prompt effect in 
diminishing the swelling. Nancrede has shown by his investigations that 
local depletion, during the hypersemic stage of inflammation, exercises a 
favorable influence in unloading the distended blood-vessels and in modi- 
fying the intensity of the subsequent conditions in the inflamed tissues. It 
is also during this stage that the application of cold proves a beneficial re- 



110 PRINCIPLES OF SURGERY. 

source in the treatment of acute inflammation, as under its effects the dis- 
tended blood-vessels contract, and in consequence of the diminution of the 
vascularity of the inflamed part the primary inflammatory swelling is dimin- 
ished. 

1. Inflammatory Exudation. — A moderate amount of swelling is pres- 
ent in all regenerative processes, as dilatation of the vessels necessarily pre- 
cedes the increased physiological activity of the tissue, and the embryonal 
material required in the reparative process occupies a larger volume than the 
mature tissue it is intended to replace. Inflammation is characterized by the 
presence of a superabundance of cells. The cause which has produced the 
inflammation has, by its direct action upon the capillary wall, produced such 
alterations of its structure as to render it more porous, hence permeable to 
the passage of the inclosed cellular elements of the blood. The albuminous 
cement-substance which holds together the endothelial cells disintegrates at 
different points, and through these small defects, the stigmata and stomata, 
the blood-corpuscles find their way through the capillary wall into the sur- 
rounding lymph- and connective-tissue spaces. In acute inflammation the 
inflammatory exudation consists principally in the extravascular accumula- 
tion of blood-corpuscles which have passed through the injured capillary 
wall. The rapidity with which the inflammatory exudation appears will 
depend on the intensity of alteration of the capillary wall and the speed 
with whrch the blood-corpuscles escape into the surrounding tissues. In 
chronic inflammation exudation takes place slowly, and the histological ele- 
ments of the inflammatory swelling are derived mostly from the fixed tissue- 
cells. Eecently it has been asserted that the inflammatory exudate of mu- 
cous and serous surfaces, or what has been considered as such, is not the 
product of cell-emigration or cell-production, but consists of a form of de- 
generation of the affected tissues. Neumann believes that it represents a 
fibrinoid degeneration of the superficial connective tissue resembling, in this 
respect, amyloid degeneration. In favor of this view is the localization of 
patches, which would not occur if there was a fluid exudate, as the rubbing 
of the pleurae or the peristaltic action of the intestines would tend to spread 
it, in inflammation of these organs. He was able to demonstrate endothe- 
lium covering the patches. Georgiewsky studied fibrinous exudates by means 
of injection of solutions of iodine. During the first twenty-four hours after 
injection, especially, appearances are presented that might be mistaken for 
a fibrinous degeneration of the connective tissue, such as Neumann claims 
takes place in fibrous inflammation of serous membranes. The connective- 
tissue fibres swell up and are loosened, the lymph-spaces are widened, and 
leucocytic infiltration takes place; but, although the fibres now take the 
fibrin-stain, the vessels always remain distinct and do not form part of the 
exudate. A certain amount of tissue-degeneration and necrosis certainly 



SYMPTOMS OF INFLAMMATION. Ill 

takes place in acute 1 inflammation, but the established views that the inflam- 
matory exudate consists largely of fibrin and the product of cell-migration 
has not been undermined by Neumann's experiments. 

Emigration of Leucocytes. — The passage of a leucocyte through a defect 
in the capillary wall is called emigration; the wandering of such a cell from 
a place where it has a normal existence into a territory where in a condition 
of health it does not exist is seldom met with. After it has made its escape 
from the capillary vessel it is called an emigration, or wandering, corpuscle. 
John Hunter came very near being the discoverer of emigration of leuco- 
cytes during his researches on inflammation. He incised the tunica vaginalis 
in animals, and inserted a tallow plug, which he removed after short inter- 
vals, and examined the fluid upon its surface under the microscope. He 
found in this fluid, a short time after the incision was made, round, white 
cells, which could have been nothing else but wandering leucocytes. 

The credit for having demonstrated the porosity of the capillary wall 
and the escape of the colorless corpuscles unquestionably belongs to Waller. 
This author observed emigration in the tongue of the frog as early as 1846, 
and strongly maintained that the inflammatory exudates were composed 
largely of leucocytes, in opposition to the blastema theory of formation of 
pus and other inflammatory products. 

In 1849 Addison clearly pointed out the relationship of the colorless 
corpuscles and the corpuscles lying around the vessels in inflamed parts, as 
becomes evident from the following sentences from his work on "Consump- 
tion and Scrofula'^: "During inflammation — using the word in the general 
sense here indicated — there is more or less marked increase of the colorless 
elements and protoplasm in the part affected. At first — in the first stage — 
these elements adhere but slightly along the inner margin or boundary of 
the nutrient vessels, and are therefore still within the influence of the cir- 
culating current, belonging, as it were, at this period as much, or rather 
more, to the blood than to the fixed solid. Secondly — in the second stage — 
they are more firmly fixed in the walls of the vessels, and, therefore, now 
without the influence of the circulating current. Thirdly — in the third 
stage — new elements appear at the outer border of the vessels, where they 
add to the texture, form a new product, or are liberated as an excretion/' 

Eecklinghausen found wandering corpuscles in the vascular spaces of 
the cornea, but he believed that they were a product of tissue-proliferation 
from the fixed corneal corpuscles. Our modern knowledge of emigration of 
leucocytes is founded almost exclusively upon the labors of Cohnheim. This 
observer demonstrated, in the year 1867, by his own ingenious experiments, 
that the wandering corpuscles discovered by Eecklinghausen in the vascular 
spaces of the cornea were leucocytes which had escaped from capillary vessels 
and had wandered into the cornea. He based his statements on the results 



112 PRINCIPLES OF SURGERY. 

of an experiment which could leave no room for discussion. He injected 
finely-divided pigment-material directly into the circulation of an animal, 
and somewhat later produced artificially a keratitis. In examining the 
cornea he found the vascular spaces nearest the margin of the cornea crowded 
with leucocytes loaded with pigment-granules. There could be only one 
conclusion, — that the leucocytes, which had become charged with pigment- 
granules in the general circulation, had passed through the capillary vessels 
at a point nearest the seat of irritation; in other words, the capillary vessels 
which took part in the traumatic keratitis furnished the primary inflamma- 
tory exudation. A slight irritation of a frog's web will only produce an 
active hyperemia, and in a short time the circulation returns to normal with- 
out any emigration of leucocytes having taken place. In such cases the irri- 
tant has been of such a nature or of such mild action as not to produce the 
necessary alteration of the capillary wall for mural implantation and emigra- 
tion to take place. 

Zahn has shown that if the mesentery of an animal is exposed, but care- 
fully protected against injury, emigration of leucocytes does not take place 
for seven or eight hours, while the remaining disturbances of the circulation 
indicate the existence of inflammation. If, however, the frog^s web or tongue 
is cauterized with a sharp-pointed pencil of nitrate of silver the necessary 
conditions for an acute inflammation are created, and the minute eschar 
is soon surrounded by vessels showing the different stages of the inflamma- 
tory process, from active hyperemia to complete stasis. Emigration of leu- 
cocytes takes place most actively in capillaries partly obstructed by mural 
aggregation of these elements, and the process is arrested as soon as the cir- 
culation has come to a complete stand-still. The following conditions must 
be present and are essential for emigration of leucocytes: 1. Alteration of 
capillary wall. 2. Mural implantation of leucocytes. 3. Permeability of 
lumen of capillary vessel. 4. Amoeboid movements of leucocytes. 

1. Alteration of the capillary wall has been repeatedly enumerated as 
the most important feature of inflammation, and without such a change the 
rapid escape of leucocytes as we find it in inflammation would be utterly im- 
possible. The cause which has produced the inflammation produces such 
a degree of softening in the cement-substance as to enable its penetration by 
the leucocytes between the endothelial cells, or, as some of the authors 
claim, localized minute defects cause the formation of small openings 
through which the leucocytes escape. 

2. Mural implantation of leucocytes is an equally essential condition, 
as without it the leucocytes, which are at any rate larger in circumference 
than the supposed openings through which they escape, would be rolled over 
these minute defects by the sluggish peripheral stream, and emigration 
would not take place. Increased adhesiveness or viscosity of the leucocytes 



SYMPTOMS OF INFLAMMATION. 



113 



is supposed to play an important part in the occurrence of mural implanta- 
tion. According to Hering, mural fixation of the leucocytes is effected by 
fine projections, which are thrown out on their surface, and which insinuate 
themselves into the small crevices of the roughened intima. Mural implanta- 
tion cannot take place as long as the capillary stream retains its normal 
velocity; hence, slowing of the peripheral current is the first and most im- 
portant cause. The slower the peripheral stream, the more readily does 
mural implantation occur, and the greater the tendency to aggregation of 
leucocytes along and near the capillary wall. The rapid transudation of the 
plasma of the blood through the defective capillary is undoubtedly another 
cause of impediment of progress and final adhesion of leucocytes to the inner 




Fig. 67.— Leucocyte Passing through Capillary Wall. A, leucocyte attached to capil- 
lary wall by delicate processes; higher up it has penetrated the capillary wall by a large 
projection. B, half of the leucocyte outside of the capillary wall dragging the remainder 
after it. (Landerer.) 

surface of the capillary vessel. Finally, mural fixation of leucocytes is ef- 
fected by the changed condition of the protoplasm of the leucocytes and the 
inner surface of the capillary wall by the action of the essential cause which 
produced the inflammation. 

3. It has been shown that emigration of leucocytes is most active where 
the capillary circulation has become impeded, but not arrested, and that the 
process is arrested with the occurrence of complete stasis; hence, it appears 
that the intravascular pressure is one of the factors in this process. Hering 
and Schklarewsky maintained that the leucocytes are entirely passive struct- 
ures in their passage through the capillary wall, that they are forced through 
defects in the wall exclusively by the intravascular pressure. That emigra- 



114 PRINCIPLES OF SURGERY. 

tion is not such a simple process is evident, as there would be in such case 
a larger representation of colored corpuscles in the inflammatory exudation. 
The blood-pressure assists in the extrusion of leucocytes that have penetrated 
the capillary wall, but, without changes in their form, would not be ade- 
quate to force them through the minute openings or the softened cement- 
substance. 

4. Leucocytes, in order to pass through an inflamed capillary wall, must 
possess amoeboid movements; hence, only living leucocytes are capable of 
migration. 

After the leucocyte has become implanted upon the inner surface of 
the capillary wall it penetrates the softened cement-substance by throwing 
out projections, or one of these projections insinuates itself into one of the 
minute foramina, and as the extramural portion increases in size the re- 
mainder of the leucocyte is drawn toward it; this step is greatly aided by 
the blood-pressure, which pushes the intravascular portion in the direction 
of the growing projection, until by its own exertions, and aided by the vis 
a tergo, it has finished its journey through the capillary wall, and has reached 
the paravascular lymph or connective-tissue spaces, where it constitutes the 
most important element of the inflammatory exudation. In the inflamed 
capillaries of the frog's web, under the microscope, this process of emigra- 
tion can be readily followed, and leucocytes can be seen in the same field in 
various stages of transit through the wall, and finally liberated in the para- 
vascular spaces. Frequently one leucocyte after another can be seen pass- 
ing through the same place: a fact which points strongly to the existence 
of well-defined circumscribed defects in the capillary wall. As the escaped 
leucocytes accumulate outside of the capillary vessels, some of them can be 
seen to change their location by the same forces which have been active in 
their passage through the vessel-wall: amoeboid movements and stream of 
parenchyma-fluid. 

Diapedesis. — This word was devised by Strieker to designate the passage 
of colored corpuscles through the inflamed vessel-wall. If there could be 
any doubt as to the existence of minute openings in the inflamed capillary 
wall in the consideration of emigration of leucocytes, this doubt must be 
effectually dispelled when the passage of colored corpuscles through the 
capillary wall can be demonstrated under the microscope. Experimental 
research and clinical observation have shown that when the inflammatory 
action is very intense red corpuscles form no inconsiderable part of the in- 
flammatory exudation. As the colored corpuscles possess only limited amoe- 
boid movements, their passage through the capillary wall must be largely a 
passive process: they are extruded through preformed openings or through 
an exceedingly soft cement-substance by the intravascular pressure. It is 
possible that they are forced through passages made by the emigration cor- 



iYMPTOMS OF INFLAMMATION. 



L15 



puscles. It is well known that at firsl only leucocytes are found outside of 
the capillary vessels, that the colored corpuscles appear later, and that, while 
leucocytes also pass through the smallest veins, the colored corpuscles escape 
only through capillary vessels (Fig. 68, D). 

Arnold noticed that red corpuscles floating in the capillary stream, 
when they arrived opposite a stoma, were drawn toward the opening of the 
transudation-strcam. 

Diapedesis becomes a prominent feature where the inflammatory process 
is very acute, consequently where extensive alteration of the vessel-walls has 
taken place. In such instances the colored corpuscles are so numerous in 




Fig. 68. — Inflammation of Frog"s Web at Stage where Capillary Stream is Impeded 
by Commencing Emigration. A, small artery; B, small ,vein; C, capillaries; D, red 
corpuscles which have escaped from capillary by diapedesis. (Latulerer.) 

the exudation as to impart to it a ha3morrhagic appearance. An abundant 
escape of colored corpuscles in inflammation is technically called rhexis. 
The third corpuscles are extruded through the inflamed capillary wall in the 
same passive way as the colored corpuscles. 

The primary inflammatory exudation consists of the corpuscular ele- 
ments of the blood which escape through the porous capillary wall, the prod- 
ucts of their disintegration, and blood-plasma. The latter will be again 
referred to under the head of "Transudation/"' The presence of the solid 
constituents of the blood differentiates the inflammatory exudation from an 
ordinary hydropic or cedematous swelling. The question arises: What be- 



116 PRINCIPLES OF SURGERY. 

comes of the corpuscular elements after they have left the general circula- 
tion? The most favorable termination of the inflammatory process consists 
in the preservation of the vitality of the cellular elements outside of the 
blood-vessels and their return into the general circulation by a process which 
is called immigration. This probably seldom, if ever, takes place in the case 
of the colored and third corpuscles, which undergo molecular disintegra- 
tion, and the granular detritus is removed by absorption. The leucocytes 
which have retained their vitality can return into the circulation either by 
reentering the capillaries which they have left, after the acute symptoms 
have subsided and the capillaries have been cleared of the mural thrombi, 
or by a more indirect route through the lymphatic vessels. The latter route 
is probably the most frequent. If the blood-corpuscles contain the microbic 
cause of the inflammation in sufficient quantity and intensity to destroy their 
protoplasm, they furnish the necessary nutrient medium for the growth and 
development of the microbe outside of the vessel-wall, thus bringing it in 
direct contact with the paravascular tissues, which then become the seat of 
infection. In such instances the cellular elements of the primary inflam- 
matory exudation are dead tissue, and act or are disposed of as such. In 
acute suppurative inflammation the leucocytes which have escaped are con- 
verted into pus-corpuscles. The emigration corpuscle under no circumstances 
assumes a tissue-producing function. When inflammatory processes result 
in the formation of new tissue, this function is performed by fixed tissue- 
cells which have been stimulated to a state of activity by the increased 
nutritive conditions incident to some forms of inflammation. The albumen, 
which is always present in considerable quantity in every inflammatory exu- 
dation, furnishes an additional nutrient supply, and thus assists the process 
of cell-proliferation; this is especially the case with the globulins. The 
filtrate which percolates through the inflamed capillary wall contains co- 
agulable substances, which, in hydropic fluids, are less abundant. The emi- 
gration corpuscles, which disintegrate soon after they have left the capillary 
vessels, furnish fibrin-ferment. Fibrin-production in the tissues is sus- 
pended as soon as the product of emigration has become copious, The third 
corpuscles furnish another source of fibrin-production. In suppurative in- 
flammation fibrin-formation does not take place. Where no fibrin forms in 
the exudation, the supposition lies near that the fibrin-producers are taken 
up by the cells, or that the fibrin which had already been produced is lique- 
fied and assimilated by them. If the inflamed vessels are surrounded only 
by a few leucocytes, the latter are destroyed and liberate fibrin-ferment; if 
abundant, they are more resistant and destroy albuminous substances. 
Weigert asserted that cell-necrosis resulted in the formation of fibrin, as the 
dead cells furnish the fibrin-ferment. That, fibrin-production does not al- 
ways attend inflammation can only be explained by the supposition that the 



SYMPTOMS OF INFLAMMATION. 117 

fibrin-producers are assimilated as soon as they have left the blood-channels. 
If the cells which furnish the fibrin come in contact with necrotic tissue, 
such an assimilation is prevented and fibrin is formed. Fibrin-production, 
however, may take place without cell-necrosis, as is the case upon inflamed 
serous surfaces. Its occurrence in this particular locality can only be ex- 
plained by the absence of accumulation of the cells which yield the fibrin- 
ferment. The cellular constituents and fibrin of the inflammatory exuda- 
tion impart to it one of its characteristic clinical features, — a sense of firm- 
ness, — which is well marked in proportion to the predominance of these 
over the fluid portion. 

2. Inflammatory Transudation. — The liquid portion of the blood which 
escapes through the damaged wall of inflamed capillary vessels is called in- 
flammatory transudation. The same causes which are necessary to extrude 
the non-amoeboid corpuscular elements of the blood constitute also the con- 
ditions which enable a part of the blood-plasma to leave the capillary stream. 
Increased porosity of the capillary wall is the most important of them. As 
soon as the capillary wall has become abnormally permeable the blood-press- 
ure forces the fluid through the minute pores into the surrounding con- 
nective tissue, or, if the inflammation is located in a mucous or serous mem- 
brane, upon the surface. In deep-seated inflammation the transuded fluid 
freely percolates through the connective-tissue spaces, and gives rise to one 
of the well-known symptoms of inflammation: the inflammatory oedema. 
The transudation is always more widely diffused than the exudation. Ee- 
cent bacteriological researches have shown that, while in the tissues, at the 
seat of exudation, the presence of the microbic cause of the inflammation can 
be readily demonstrated by microscopical examination and cultivation ex- 
periments, the oedema-fluid some distance from them was found free from 
microorganisms. The escape of blood-plasma in inflammation is a process 
which resembles percolation through a porous membrane. As the blood- 
plasma contains fibrinogen and fibrinoplastic material, its presence in the 
tissues or upon inflamed serous or mucous membranes is important in the 
production of fibrin. In some instances the inflammatory product is greatly 
changed by the presence of a copious transudation, and the inflamed part 
then presents more the appearance of oedema than inflammation. This is 
well shown by the two clinical varieties of anthrax. The expression serous 
inflammation is used to indicate the predominance of transudation over exu- 
dation in some forms of inflammation. The liquid transudate predominates 
over the exudate in some forms of suppurative inflammation (purulent 
oedema of Pirogoff), also when the circulation is feeble, as in the aged and 
in anaemic individuals. The addition of mucus alters the character of an 
exudation or a transudation, as may be seen when a mucous membrane is the 
seat of inflammation. Serous transudation often precedes mucous exuda- 



118 PRINCIPLES OF SURGERY. 

tion, as in cases of acute catarrhal inflammation of the nasal passages. After 
the acute symptoms of inflammation have subsided and the capillary circula- 
tion has been restored, the transuded fluid is absorbed, and with its absorp- 
tion the inflammatory oedema disappears. In suppurative inflammation the 
transudation becomes the pus-serum. 

(d) Heat. — Increase of temperature of the inflamed part is the result 
of increased afflux of blood and the accompanying augmentation of physio- 
logical processes. Cohnheim showed experimentally that inflammation, 
without an increased blood-supply, does not give rise to an increase of tem- 
perature. John Hunter was already aware that the temperature at the seat 
of inflammation is never in excess of the temperature of the blood. Heat is 
both a subjective and objective symptom. In acute inflammation of the 
skin, or a mucous membrane, the patient often complains of a distressing 
burning or scalding sensation, which is often effectually relieved by cold 
applications. The surface thermometer is sometimes an important instru- 
ment in settling a differential diagnosis between a deep-seated chronic in- 
flammation and a malignant tumor. Diminution of temperature may in- 
dicate either a favorable change or complete arrest of circulation in the in- 
flamed part, in the first instance showing that resolution is in progress, in 
the latter announcing the speedy occurrence of gangrene. 

(e) Disturbance of Function.- — As inflammation, wherever it occurs, 
consists essentially of increased nutritive changes in the tissues, resulting 
in consequence of a more abundant blood-supply and an exaggerated vegeta- 
tive capacity of the cells, it may lead to at least a temporary increase of func- 
tion. This is always the case in inflammation of mucous membranes, where, 
as one of the prominent clinical features, we observe an increased secretion 
of mucus usually preceded and accompanied by a more or less profuse tran- 
sudation. Parenchymatous inflammation in glands usually produces sudden 
diminution and often complete suppression of secretion. Acute suppurative 
osteomyelitis is attended by almost complete suspension of all the functions 
of the affected limb. Myositis arrests the contractility of the muscles af- 
fected. The pain caused by an inflammation may interfere with the func- 
tions of adjacent organs, as may be seen in the fixed chest-wall in cases of 
acute pleuritis, and in fixation of the abdominal walls, with diminished or 
suspended respiratory movements of the diaphragm, in cases of peritonitis. 
The accumulation of inflammatory products may prove a serious obstacle 
to important functions, and often constitutes a direct cause of death, as in 
cases of intracranial inflammation, where death is more frequently caused 
by compression of the brain than destruction of the contents of the cranial 
cavity; and the accumulation of serum or pus in the pleural cavity or peri- 
cardium, where a fatal termination can often be traced to mechanical causes 
from the presence of a copious effusion. Diminution of function often 



SYMPTOMS OF INFLAMMATION. 119 

affords the earliest indication of the existence of a deep-seated chronic in- 
flammation, as is evident from the slight limp which nshers in a coxitis or 
the imperfect flexion and extension in chronic inflammation of joints other 
than the hip-joint. 



CHAPTER V. 

Inflammation {continued). 

MODIFICATION OF INFLAMMATION BY THE ANATOMICAL STEUCTUKE 
AND LOCATION OF THE INFLAMED TISSUE. 

The clinical course and pathological conditions of inflammatory proc- 
esses are materially modified, not only by the primary cause, but also by 
the anatomical structure and location of the inflamed tissues. Inflamma- 
tion of serous or mucous surfaces has a tendency to spread in a peripheral 
direction, and, as a rule, remains superficial, and the exudation and tran- 
sudation are poured out in the direction offering the least resistance; that 
is, upon the free surface. In tissues that are dense and unyielding the 
swelling, for physical reasons, is limited, and the inflammatory products give 
rise to tension, which may arrest the circulation completely and cause ne- 
crosis, as is the case in acute suppurative osteomyelitis. When the area of 
inflammation is supplied with an abundance of connective tissue the swell- 
ing often attains enormous dimensions in a short time, as may be seen in 
every case of phlegmonous inflammation of the deep-seated connective tis- 
sue of the extremities, neck, chest, and abdomen. Acute inflammation of 
organs that are exceedingly vascular gives rise to an early and abundant 
exudation, as can be demonstrated in every case of croupous pneumonia and 
acute nephritis. Inflammation of non-vascular tissue is accompanied by the 
formation of new blood-vessels, which grow in the direction of the seat of 
inflammation from the nearest vascular district. Some tissues are more 
disposed to inflammation than others; thus, the connective tissue is more 
frequently the seat of acute inflammation than muscles, and the medullary 
tissue than the bone-substance proper, and most causes which give rise to 
chronic inflammation are known to select certain organs and tissues in prefer- 
ence to others. 

PAKENCHYMATOUS INFLAMMATION. 

In the study of the cardinal symptoms of inflammation special atten- 
tion was given to the part taken in the inflammatory process by the capil- 
lary vessels and the blood-corpuscles. Alteration of the capillary wall was 
alluded to as the most important pathological condition, as upon it depends 
the emigration of the corpuscular elements of the blood and the occurrence 
of the inflammatory transudation, which together constitute the primary 
inflammatory swelling. Incidentally it was stated that, as soon as the cause 
which gave rise to the inflammation is brought in direct contact with the 

(120) 



PARENCHYMATOUS INFLAMMATION. 121 

fixed tissue-cells, these take part in the inflammatory process and contribute 
their share to the inflammatory exudation. Inflammation is said to be 
parenchymatous when the parenchyma of an organ is the primary seat of 
inflammatory changes, as when the secreting structures of a gland are im- 
plicated from the beginning. In all such instances the blood-vessels which 
furnish the vascular supply have undergone the characteristic changes which 
have been described, and with few exceptions the microbes have been con- 
veyed to the parenchyma through them. The cloudy swelling of paren- 
chyma-cells is either an evidence of the existence of degenerative changes or 
it denotes the beginning of coagulation-necrosis from the specific effect of 
pathogenic microbes upon their protoplasm. A cloudy appearance of cells 
is one of the first manifestations of the presence of a parenchymatous in- 
flammation. Lesion of connective-tissue or parenchyma- cells is next to 
alteration of the capillary wall, and emigration of the blood-corpuscles the 
most important pathological condition of inflammation, and, as far as the 
ultimate result is concerned, the most important, as extensive destruction 
of parenchyma-cells will result in suspension of function, and death of the 
organ affected. As soon as the fixed tissue-cells outside of the vessel-wall 
have become implicated their physiological resistance is diminished: a 
condition which cannot fail in aggravating the existing vascular disturb- 
ances. Landerer maintains that the normal elasticity of the tissues sur- 
rounding the capillary vessels is an essential factor in preserving the 
equilibrium between the intravascular pressure and the surrounding tissues 
in a normal condition of the circulation. This mechanical theory of inflam- 
mation is founded upon the supposition that this normal elasticity of the 
paravascular tissues is diminished by the causes which give rise to inflam- 
mation, and that when this has occurred the capillary walls have lost 
their outer support, in consequence of which they become dilated, and 
hyperemia, slowing of blood-current, emigration, and transudation fol- 
low as the result of purely mechanical causes. Ingenious as this theory 
may appear, it cannot explain the complicated processes which characterize 
inflammation. The train of pathological conditions which attend inflamma- 
tion must be regarded as effects of a common microbic cause upon the capil- 
lary wall, their contents, and the fixed tissue-cells outside of the capillary 
vessels. In parenchymatous inflammation the cause has reached the 
parenchyma-cells, either directly, as when microbes are brought in con- 
tact with a mucous surface, become attached to and penetrate the paren- 
chyma-cells, multiply in their interior, and, later, reach the connective tis- 
sue and blood-vessels, or, what is more common, the microbes reach the 
parenchyma through the circulation. In both instances the capillary ves- 
sels and the connective tissues between them and the parenchyma-cells take 
an active part in the inflammatory process. The microbes may be present 



122 PRINCIPLES OF SUBGEEY. 

in such great number or may possess such intensely virulent properties as to 
destroy the parenchyma-cells, as is the case in diphtheritic inflammation of 
mucous membranes. When less intense in their action the parenchyma-cells 
proliferate, and the embryonal cells, being less resistant, succumb later, as 
when suppuration occurs in the parenchyma of an organ, or they remain in- 
definitely in their embryonal state, as can be readily verified by examining 
the different forms of chronic inflammatory swelling: the so-called granulo- 
mata. 

INTERSTITIAL INFLAMMATION. 

In this form of inflammation the connective tissue is the primary seat of 
cell-emigration and tissue-proliferation. Many of the microbes select the 
connective-tissue spaces; they locate and multiply here, and the inflamma- 
tory product is composed almost exclusively of emigration-corpuscles and 
embryonal connective-tissue cells. Tubercle and gummata present such a 
histological structure. Phlegmonous inflammation represents the acute form 
of connective-tissue inflammation. If the connective tissue of an organ 
becomes the seat of an inflammatory hyperplasia the parenchyma suffers, 
either in consequence of pressure or, later, from cicatricial contraction and 
the inevitable diminution of blood-supply incident to this condition. Paren- 
chymatous inflammation of an organ is preceded or followed by interstitial 
inflammation, and a primarily interstitial inflammation sooner or later in- 
volves the surrounding tissue by direct extension of the inflammatory proc- 
ess, or indirectly by the mechanical causes; hence, as a rule, it is anatomic- 
ally and even etiologically not always possible to differentiate between these 
two forms of inflammation, nor is such a distinction of much practical im- 
portance. 

HEMORRHAGIC INFLAMMATION. 

A few colored corpuscles escape through the capillary wall in almost 
every case of acute inflammation, but their presence in the exudation can 
only be determined by the use of the microscope. When they are present 
in sufficient number to impart to the exudation a bloody tinge, we speak 
of a hemorrhagic exudation or transudation. A haemorrhagic transudation 
into the pleural, pericardial, or peritoneal cavity usually indicates the ex- 
istence of a tubercular or malignant disease of the respective serous mem- 
branes. In cases of acute inflammation with haemorrhagic exudation, the 
quantity of the effused blood will be a sign by which we can at least approxi- 
mately estimate the extent of alteration of the capillary wall. Ehexis can 
only take place when the capillary wall at some point has been completely 
broken down and an opening of considerable size has formed through which 
a small stream from the axial current can escape. Aside of the nature and 



INFLAMMATION OF SEKOUS MEMBRANES. 123 

intensity of the primary cause of the inflammation, hemorrhagic inflamma- 
tion is more likely to be met with in persons debilitated from other diseases, 
in the aged, and in patients suffering from diseases which obstruct the cir- 
culation, snch as valvular disease of the heart, cirrhosis of the liver, em- 
physema of the lungs, and chronic affections of the kidneys. The presence 
of blood in a transudation or exudation is always a grave sign, and as snch 
should always be taken into careful consideration in rendering a prognosis. 

SUPPURATIVE INFLAMMATION. 

In suppurative inflammation at least a part of the exudation is trans- 
formed into pus. Transformation of the cellular portion of the exudation, 
the leucocytes and embryonal cells, into pus-corpuscles is due to the de- 
structive effect upon their protoplasm of the pus-microbes and their tox- 
ins, while the transudate becomes the pus-serum. Suppurative inflam- 
mation occurs either as the result of a primary or secondary infection with 
pus-microbes. In primary infection with pus-microbes the leucocytes most 
remote from the blood-vessels, and which have been exposed longest to the 
specific action of the pus-microbes and their toxins, are converted first 
into pus-corpuscles, while the fixed tissue-cells are first transformed into 
embryonal cells before the same cause — by destruction of their protoplasm — 
changes them into similar structures. In suppurative inflammation due to 
secondary infection the pus-microbes act upon embryonal cells which owe 
their origin to an antecedent infection with another microbe of milder 
pathogenic qualities, as can be seen when tubercular granulations or a 
gumma undergo suppuration. Suppurative inflammation, in all of its as- 
pects, will be fully considered in the chapter on "Suppuration.*' 

IXFLAMMATIOX OF SEROUS AIEAIBRAXES. 

Inflammation of the serous membranes has been called exudative, ad- 
hesive, suppurative, or serous, according to the character of the inflamma- 
tory product. In most inflammatory affections of the serous membranes 
the surface becomes covered with a copious exudation, which is composed 
of leucocytes, fibrin, and the products of tissue-proliferation of the endo- 
thelial and connective-tissue cells. The leucocytes and third corpuscles are 
rapidly destroyed as they reach the surface, and the fibrin-ferment and 
fibrinoplastic material which are liberated form — on combining with the 
fibrinogen f the blood-plasma — fibrin. The inflamed membrane is often 



'to' 



covered by a thick layer of fibrin, which is firmly adherent to the surface 
by means of new blood-vessels and granulation-tissue which have grown into 
it. The endothelial cells take an active part in the inflammation, and in case 
the new product from this source is converted into connective tissue a per- 



124 



PRINCIPLES OF SURGERY 



manent adhesion forms. In some instances the endothelial cells are de- 
stroyed and desquamation takes place, which leaves the subjacent connective 
tissue exposed. In such cases the superficial dilated capillaries have lost an 
important support, and transudation takes place freely. D. J. Hamilton has 
studied the histological changes which occur in peritonitis by producing this 
disease artificially in young dogs. Besides desquamation, he has seen the 
endothelial cells multiply by division of the nucleus. 




Fig. 69. — Germinating Endothelium, Omentum of Young Dog. Acute Peritonitis. 
Silver Staining. X 350. A, natural endothelium covering wall of a mesh; B, D, endo- 
thelial cells beginning to germinate; C, a chain of germinating cells extending across a 
fenestra; E, mass of germinating endothelial cells. (Hamilton.) 

The new cells resemble the ordinary granulation or embryonal cells. 
The connective tissue between the endothelial lining and the blood-vessels 
undergoes tissue-proliferation, and the new cells reach the surface and min- 
gle with those derived from the endothelial lining, so that the inflamed sur- 
face becomes covered with a layer of granulation-tissue. The granulations, 
accompanied by dilated or new blood-vessels, penetrate into the fibrinous 



i\n. amm \Tlo\ ov SEROUS MEMBRANES. 



125 



exudation, which is removed in the same manner as a thrombus in a blood- 
vessel undergoing obliteration. Permanent adhesions and obliteration of 
serous cavities are effected by the granulation-tissue, which removes the in- 
flammatory exudation and establishes an organic union between opposing 




pig 70 —Omentum of Young Dog, Experimentally Inflamed. X 450. A, pyriform 
cell probablv of endothelial origin, sprouting from wall of a fenestra (8) of the mem- 
brane; C, capillary, surrounded by extravasated leucocytes; V, small vein, in similar 
condition. (Hamilton.) 



inflamed membranes. If the fixed tissue-cells do not participate actively in 
the inflammatorv process, the exudation becomes absorbed in the course of 
time, and the endothelial lining is repaired; thus the temporary adhesions 
are removed, and the normal relations existing between the serous membrane 
and inclosed viscera are restored. The blending of the corpuscular elements 



126 



PRINCIPLES OF SURGERY. 



of the inflammatory exudation of a serous membrane with the product of 
tissue-proliferation of the endothelial cells is well shown in Fig. TO. 

The pathological anatomy of acute inflammation of a serous membrane 
at an early stage is well represented in Fig. 71. 

The scarcity of leucocytes in the fibrin in the specimen represented by 
this illustration was undoubtedly due to their rapid destruction as soon as 
they reached the surface, which resulted in the formation of a copious de- 
posit of fibrin. The round cells in the subpleural connective tissue are 




Pig_ 7x. — Acute Pleurisy. X 300. A, A, net- work of fibrin: B, an effused leucocyte; 
C, laminse of fibrin lying adjacent to the pleura (F) ; D, small round cells effused into 
the pleura; E, distended blood-vessel of the superficial layer of pleura. (Hamilton.) 

wandering leucocytes. Sufficient time does not seem to have elapsed for any 
marked changes to have occurred in the fixed tissue-cells. In suppurative 
inflammation of a serous membrane, if life is sufficiently prolonged, the 
leucocytes and embryonal cells are transformed into pus-corpuscles, and in 
this manner empyema, pyocardium, and purulent peritonitis are produced. 
The introduction of pus-microbes in sufficient quantity into the abdominal 
cavity, the power of absorption of which has been reduced by an antecedent 
affection or an accompanying trauma, will produce such a rapidly fatal 



INFLAMMATION OF MUCOUS MEMBRANES. [% r t 

peritonitis that the peritoneum, on post-mortem examination, will show 
little, if any, macroscopical lesions. Death in such cases results from acute 
septic infection. When life is prolonged for several days, the post-mortem 
reveals all the evidences of a fibrinoplastic peritonitis; that is, numerous 
adhesions between the intestines and the parietal peritoneum and among the 
intestinal loops. In suppurative peritonitis the exudation often breaks down 
as the leucocytes contained in it are converted into pus-corpuscles. Tuber- 
cular peritonitis is usually attended by a copious exudation, which limits the 
process and encapsulates the serous transudation. If, in an inflammation 
of a serous membrane, the transudation predominates over the exudation, 
the character of the process is indicated clinically by a subacute or chronic 
course and the absence of severe symptoms. Hydrothorax often develops 
insidiously, and perhaps the first subjective symptom is difficulty of breath- 
ing. Tubercular peritonitis with copious circumscribed effusion has been 
frequently mistaken for ovarian cyst, not only because the swelling closely 
resembles a unilocular ovarian cyst, but also from the absence of any of the 
usual local symptoms which attend the different forms of fibrinoplastic peri- 
tonitis. It appears that the causes which give rise to this form of inflamma- 
tion of serous membranes do not act with sufficient intensity on the capil- 
lary wall and the paravascular tissues to provoke a copious exudation and 
active tissue-proliferation, but create conditions which permit a copious 
transudation to take place. It has been recently a much-discussed question 
whether or not all cases of serous effusion into the chest are of tubercular 
origin. The fact remains that many cases of subacute and chronic pleurisy 
die subsequently from tuberculosis, and the natural conclusion would be that 
the disease was primarily caused by a localized tubercular focus, which, at the 
time, could not be detected. It is evident that the causes which produce 
serous transudation do so not only by producing changes in the capillary wall 
which permit free transudation, but also by bringing about alterations which 
diminish or completely suspend the power of absorption; hence, not only the 
occurrence of transudation, but accumulation of the liquid effused. The 
presence of blood in the transudation is usually an indication of the presence 
of tuberculosis, carcinoma, or sarcoma. 

IXFLAMMATIOX OF MUCOUS 3IEMBBAXES. 

Inflammation of a mucous membrane represents another variety of sur- 
face inflammation which is greatly modified by the anatomical character of 
the tissue the seat of the inflammatory process. We have seen that inflam- 
mation of serous membranes presents as its most characteristic pathological 
feature a plastic exudation on its surface, composed of escaped blood- 
corpuscles and the products of their disintegration, which are firmly attached 
to the endothelial lining, which, in part, has been destroyed and detached 



128 PRINCIPLES OF SURGERY. 

by desquamation, while the cells which have retained their vitality proliferate 
new tissue, which mingles with and ultimately removes the exudation. The 
epithelial cells which line mucous membranes when in a state of inflamma- 
tion are stimulated to increased activity, and consequently secrete an in- 
creased quantity of mucus, which is the characteristic pathological and clin- 
ical feature of 

I. CATARRHAL INFLAMMATION. 

Inflammation of a mucous membrane is called catarrhal as long as the 
product consists of an increased secretion of mucus. If a part of the mucous 
lining is destroyed and the discharge becomes a mixture of pus and mucus, 
it is no longer proper to call it a catarrhal inflammation, as the pus-microbes 
have wrought changes that bring the process within the legitimate sphere 
of suppurative inflammation. Catarrhal inflammation produces a thicken- 
ing of the mucous membrane by infiltration of the submucous tissue, which, 
if copious, may subsequently give rise to cicatricial contraction, and, if the 
inflammation is located in a tubular organ, to the formation of strictures. 
According to Yirchow, a catarrhal inflammation may lead to the formation 
of superficial ulcers, — the so-called catarrhal ulcers. 

II. SUPPURATIVE INFLAMMATION. 

In this form of inflammation of a mucous membrane, the leucocytes 
which reach its surface, as well as the embryonal cells, are destroyed by 
the pus-microbes and are converted into pus-corpuscles, which when 
mixed with the mucus secreted by the cells which have retained their 
physiological function, form the muco-purulent discharge. Most of the 
ulcers which form upon mucous surfaces result from circumscribed necrosis 
or suppurative inflammation. A catarrhal inflammation very frequently 
precedes the suppurative form, and a circumscribed suppurating area is usu- 
ally surrounded by a zone of catarrhal inflammation. Cicatricial oblitera- 
tion of a tubular organ can only take place after extensive defects of its 
mucous lining from necrotic, ulcerative, or traumatic causes. Limited defects 
are repaired by regeneration of the epithelial cells, either from the margins 
of the defect or from remnants of glands. The most frequent causes of 
ulceration in the intestinal canal are dysentery, typhoid fever, and tuber- 
culosis. Ulcers which result from the sudden obliteration of a small blood- 
vessel by thrombosis or embolism are met with after extensive burns in the 
upper portion of the small intestine and in the stomach in chlorotic females. 
A strange form of perforative enteritis has recently been described by 
Mikulicz. A similar case was operated on in the Zurich Klinik, and a care- 
ful description of the pathological conditions found at the necropsy has been 
given by Klebs. He found multiple perforations in a circumscribed portion 



INFLAMMATION OF MUCOUS MEMBBANES. 129 

of the jejunum, and only a few of them had been found and closed by the 
surgeon who performed the operation. The perforations on the peritoneal 
side were covered by a plastic exudation. The lumen of the intestine corre- 
sponding to the ail'ected portion was considerably enlarged. Mucous mem- 
brane not much changed in appearance, but, on close inspection, a number 
of small defects, partly hidden under the folds, were detected, and were found 
to correspond with the covered defects on the outer surface. On micro- 
scopical examination, it was found that the villi and mucous membrane were 
softened and denuded of the epithelial lining and infiltrated with cells over 
a considerable distance beyond the perforations. The most marked changes 
were found in the submucous tissue, which was also much softened, and the 
' scanty intercellular substance was found traversed by wide spaces in which 
were found numerous large cells with large oval nuclei. Besides these en- 
larged parenchyma-cells, and in their vicinity, leucocytes which had under- 
gone fragmentation were found. As the capillary vessels were much dilated 
and in a condition of inflammation, Klebs looks upon the process as an hy- 
perplastic parenchymatous enteritis. As the leucocytes found in the tissues 
presented all the evidences of fragmentation, there can be but little doubt 
that this rare form of enteritis presents only another variety of suppurative 
inflammation of the mucous membrane of the intestine. 

III. CROUPOUS INFLAMMATION. 

"When inflammation of a mucous membrane is attended by the formation 
of a fibrinous exudation or false membrane upon its surface, it is called 
croupous. The formation of a fibrinous exudation upon a serous surface, we 
have found, is always associated with a more or less extensive destruction 
and desquamation of endothelial cells, and a similar superficial change takes 
place in croupous inflammation. Weigert states that unless the epithelial 
surface of a mucous membrane be broken the inflammatory exudation from 
it will not coagTilate. As croupous inflammation of a mucous membrane is 
always produced by direct infection, it is probable that the microorganisms 
destroy some of the epithelial cells; and as the inflammatory process pene- 
trates deeper into the tissue, the exudation and transudation coming in con- 
tact with dead tissue on the surface, fibrin is deposited, and, becoming en- 
tangled with the cellular debris, it becomes adherent to the partially-abraded 
and uneven surface. The fibrin is arranged in layers in the form of a coarse 
net-work, in the meshes of which is a finer reticulum of the same, with leu- 
cocytes and embryonal cells thrown off from the surface. Some membranes 
contain numerous leucocytes, while in others they are destroyed in the proc- 
ess of coagulation. Separation of a false membrane takes place either by 
the mucus secreted by intact cells underneath it, or, if the mucous lining has 



130 PRINCIPLES OF SURGERY. 

been completely destroyed, by suppuration and granulation. It has been 
claimed that, pathologically, a croupous membrane differs from a diph- 
theritic exudation in that in the former the lining of the mucous membrane 
is found intact after stripping it off, while in a diphtheritic inflammation 
there is always found a loss of surface substance after removing the mem- 
brane. Upon this more apparent than real anatomical difference the dis- 
cussion on the non-identity of croupous and diphtheritic inflammation rests. 
As superficial coagulation-necrosis is present in all cases of croupous inflam- 
mation, and if this process is etiologically different from diphtheritic inflam- 
mation, the pathological conditions are different only in degree, and not in 
kind. False membranes, wherever they may form upon a mucous or serous 
surface, serve as nutrient media for microorganisms, and the underlying sur- 
face is subjected to the risks of recurring infection from them as long as 
they remain. 

IV. DIPHTHERITIC INFLAMMATION. 

Diphtheritic inflammation is caused by the Klebs-Lofner bacillus. As 
a primary disease it affects most frequently the upper part of the respiratory 
tract. Extensive destruction of the mucous membrane underneath the exu- 
dation is a constant occurrence. Diphtheritic inflammation is frequently 
complicated by secondary infection with pus-microbes and saprophytes: 
an occurrence which greatly aggravates the local conditions and increases 
the danger to life. 

INFLAMMATION OF NON-VASCULAR TISSUE. 

The importance of blood-vessels in inflammation can be best shown by 
a study of the pathological conditions in inflammation of non-vascular tis- 
sue. The part taken by the blood-vessels and the fixed tissue-cells in the 
inflammatory process can be most satisfactorily demonstrated in non-vas- 
cular organs. 

Cornea. — Cohnheim first demonstrated emigration of the colorless 
blood-corpuscles in artificially-produced keratitis. He cauterized the cornea 
in animals, and then observed cell-infiltration from its margins at a point 
corresponding to the nearest vascular supply. For the purpose of showing 
that the cells were not products of the fixed tissue-cells he injected, a few 
days before cauterization, finely-divided cinnabar into the circulation, and 
found that the leucocytes, as they escaped from the capillary vessels, con- 
tained granules of the pigment which he had injected. The leucocytes were 
seen to wander through the vascular spaces of the cornea toward the seat 
of cauterization. As he could observe no changes in the fixed corneal cor- 
puscles at the seat of cauterization, he maintained that the inflammatory 
product was derived exclusively from the blood, and that its escape from the 



[NFLAMMATION OF NON-VASCULAR TISSUE. 131 

blood-streams depended on alteration of the capillary wall. He regarded 
the dilatation of blood-vessels, which occurs soon after the application of 
the irritant, as a result of reflex action, and attempted to prove, by specimens 
of keratitis stained with chloride of gold, that the fixed tissue-cells remained 
unaffected by the inflammation. Strieker maintained the opposite view, and 
proved, in silver-stained specimens, that the corneal corpuscles had under- 
gone changes which indicated that they performed an active part in the in- 
flammation. Eecklinghausen resorted to a very ingenious experiment to 
establish his theory regarding the origin of the wandering cells in the vas- 
cular spaces of the cornea. He cauterized the cornea of a frog, excised it 
immediately, and kept it under conditions favorable to cell-vegetation, and 
found, later, wandering cells in the vascular spaces, the origin of which he 
traced to tissue-proliferation of the corneal corpuscles after excision; but 
even his assistant, F. A. Hoffmann, expressed the opinion that the cells 
might have been leucocytes which had entered the vascular spaces before the 
cornea was excised. It is more than doubtful that tissue-proliferation would 
take place in an excised cornea, even under the most favorable physical con- 
ditions. There can be no doubt whatever that the primary exudation in 
traumatic keratitis, as in all other forms of acute inflammation, takes place 
from inflamed capillary vessels, as Cohnheim has demonstrated so beauti- 
fully; but this constitutes only a part of the phenomena which characterize 
inflammation in the cornea and all other tissues, as, later, the fixed tissue- 
cells participate in the process, and the new cells derived from them form a 
part of the inflammatory products. The parenchymatous changes are even 
more important than the vascular, as repair after subsidence of inflamma- 
tion is accomplished exclusively by proliferation of the fixed tissue-cells. 
Eberth has demonstrated, by his accurate histological researches, that the 
corneal corpuscles near an eschar, made for the purpose of producing a 
keratitis, multiply by karyokinesis, and regeneration is effected exclusively 
by the embryonal cells derived from this source. The corneal corpuscles 
possess a high vegetative capacity — resembling in this respect the connective 
tissue, to which they bear a strong resemblance, having a similar embryo- 
logical origin — and receive their nutritive supply through a system of lymph- 
channels or vascular spaces which are in intimate relationship with the scle- 
rotic vessels at the border of the cornea. The plasma- or lymph- channels in 
the cornea are loosely filled with a liquid albuminoid substance, in which 
can be seen, even in a normal condition, occasionally, a lymph-corpuscle. In 
artificial keratitis these channels are first packed with leucocytes, which 
escape from the congested capillaries at the limbus cornea?, enter them 
directly, and wander toward the seat of irritation far in advance of the new 
blood-vessels. Infiltration of the cornea with leucocytes gives rise to cloudi- 
ness. At first Cohnheim claimed that infiltration of the cornea always oc- 



132 PRINCIPLES OF SURGERY. 

curred from the periphery, but in some of the later experiments on the 
cornea? of spring frogs he noticed cell-accumulation around the central 
eschar made with a sharp pencil of nitrate of silver, and, as he was absolutely 
opposed to the idea that the corneal corpuscles could take any active part 
in the process, he came to the forced conclusion that the cellular elements 
of the conjunctival fluid were increased, and that these had wandered into 
the cornea through the lesion at the centre. Strieker has observed karyo- 
mitotic changes in the corneal corpuscles surrounding a central eschar as 
early as three hours after cauterization, and, after twenty-four to forty-eight 
hours, cell-proliferation was seen to be present all around the inflamed area. 
From what different authors have written on the subject of artificial 
keratitis, — which, of course, must be accepted as a fair representative of the 
clinical forms of this disease, — it becomes apparent that the first evidence of 
inflammation is an increased amount of fluid in the vascular spaces, causing 
distension and, consequently, swelling of the cornea. As the plasma-canals 
become distended, the cells lining them are, in part, destroyed, and the fluid 
escapes between two lamina? and forces them partly asunder. (Fig. 72, C, C.) 
At this time the endothelial cells and corneal corpuscles undergo tissue- 
proliferation, and the new cells form part of the inflammatory product. With 
the breaking down of the vascular spaces resulting in lymph-stasis, accumu- 
lation of lymph-corpuscles also takes place, by which another cellular ele- 
ment is added to the inflammatory product. The plasma-channels and arti- 
ficially-formed spaces between lamina? are now blocked with leucocytes, 
lymph-corpuscles, and embryonal cells. If the irritation is prolonged for a 
sufficient length of time, vascularization of the inflamed cornea will take 
place, in the course of one or two weeks, by the formation of new vessels 
from preexisting sclerotic vessels at the corneal border. The new blood- 
vessels grow in the direction of the seat of irritation, occupying a triangular 
field, with the apex directed toward the centre, the base corresponding to the 
limbus cornea?. The vascular portion of such a cornea is called a pannus. 
In suppurative keratitis the nuclei of the emigration-corpuscles undergo 
fragmentation and the corpuscles are converted into pus-corpuscles; at the 
same time the embryonal cells exposed to the action of the pus-microbes fur- 
nish another histological source for pus production. The fibrous tissue 
within the suppurating area necroses, on account of the disturbed nutrition 
and the toxic effect of the pus-microbes and their toxins, and an abscess re- 
sults. Vascularization of an inflamed cornea furnishes one of the most beau- 
tiful illustrations of the presence of protective resources in the organism, 
which, when called upon to meet different emergencies, render material aid 
in the prevention or limitation of destructive processes. Every oculist is 
familiar with the fact that extensive suppurative keratitis manifests no tend- 
ency to reparative action when conditions are present that retard or com- 



INFLAMMATION OF NON-V ASCL L A K TISSUK. 



133 



pletely prevent the formation of a pannns. As soon as the process of repair 
has been completed the new vessels disappear, leaving a transparent cornea 
if the defect has been within the limits of the regenerative capacity of the 
tissues; in case the loss of substance has been too great for complete restora- 
tion of structure and function, healing is accomplished by the formation of 
ordinary cicatricial tissue, which results in the formation of a scar: a per- 
manent opacity of the cornea. In keratitis without suppuration, or attended 




-D 



... C 



Fig. 72.— Artificial Keratitis. Kitten. Silver Staining. X 450. A, isolated and nu- 
cleated cell; B, a group of such still retaining something of the shape of a plasma-canal; 
G, C, plasma-canals breaking into fragments; D, the fibrous basis of the lamellae, or the 
ground-substance. (Hamilton.) 



by a limited ulceration, the cloudiness of the cornea resulting from cell- 
infiltration and the presence of embryonal cells in moderate abundance, 
transparency is restored with the removal of the wandering cells by gran- 
ular degeneration and absorption, or their return into the circulation, and 
the repair of the lesion by the transformation of the embryonal cells into 
mature, perfect, corneal tissue. 

Cartilage. — Cartilage is a structure not onlv devoid of blood-vessels, 



134 PRINCIPLES OF SURGERY. 

but also of any kind of vascular spaces for plasma circulation. Nutrition 
must here take place by intercellular and intracellular diffusion of plasma. 
In its structure it resembles the cornea. On account of the absence of any 
direct or indirect connection of cartilage-tissue with the vessels of the peri- 
chondrium, all regenerative processes are slow and imperfect, and the inflam- 
matory lesions, which only occasionally are found here as a primary affection, 
are noted for their chronicity. Artificial chondritis was studied by Goodsir 
and Eedfern. Certain parenchymatous changes were noted at different times 
after cauterization of articular cartilage. They consist essentially in the 
enlargement of the cartilage-cells, with increase of the nuclei, or of peculiar 
corpuscles contained in them, or with fatty degeneration of their contents 
and fading or similar degeneration of their nuclei. The hyaline intercellular 
substance at the same time splits up and softens into a gelatinous and finely 
molecular and dotted substance. When molecular disintegration or ulcera- 
tion of cartilage takes place, the enlarged cartilage-cells on the surface are 
liberated and the cement-substance disappears in a similar manner after 
having undergone liquefaction. Kiiss stated that he had recognized, in 
articular cartilage under the influence of irritants, certain fibrous transforma- 
tions, and believed that he had seen, in one case, changes taking place within 
the cartilage-cells. If articular cartilage be examined in the neighborhood 
of an ulcerated spot, a complete separation of the fibres — the existence of 
which in its laminated structure was demonstrated by Thin, by a special 
method of silver staining — and its reversion to ordinary white fibrous tissue 
can be readily made out. 

"Weber describes new vessels as not only extending over the surface of 
the ulcerating cartilage, but afterward penetrating its substance. In long- 
standing ulceration of cartilage a well-marked pannous condition is usually 
found present, which has resulted from the development of new blood-ves- 
sels from the vessels of the perichondrium, which grow in the direction of 
the inflammatory focus in the same manner as in keratitis. Defects of carti- 
lage caused by inflammation, like defects resulting from a trauma, are only 
partially repaired on account of the low vegetative capacity of the cartilage- 
cells, and the product of tissue-proliferation is transformed into connective 
tissue. 

PHAGOCYTOSIS. 

Until some sixty years ago humoral pathology was the prevailing one. 
Since that time, through the influence of the epoch-making labor of Virchow 
and his followers, the cellular pathology has been established. 

It has been known for a long time that absorbable aseptic tissues in 
the living body are capable of removal by the action of certain cells. The 
absorption of aseptic catgut ligatures by leucocytes and embryonal cells, 



PHAGOCYTOSIS. 135 

which accumulate around it and, later, infiltrate it, affords a good illustra- 
tion of this. MetschnikolFs paper on phagocytosis was published in 1884, 
three years after Sternberg had placed himself on record in reference to the 
destruction of pathogenic microbes by leucocytes. In 1881 the latter author, 
in a paper read before the American Association for the Advancement of 
Science, used the following language: — 

"It has occurred to me that possibly the white corpuscles may have the 
office of picking up and digesting bacterial organisms which by any means 
find their way into the blood. The propensity exhibited by the leucocytes 
for picking up inorganic granules is well known, and that they may be able, 
not only to pick up, but to assimilate and so dispose of the bacteria which 
come in their way does not seem to me very improbable, in view of the fact 
that amoebae, which resemble them so closely, feed upon bacteria and similar 
organisms." 

Metschnikoff has introduced the term phagocytosis to designate a process 
by which leucocytes and other cells remove dead material and destroy or 
digest pathogenic microorganisms. The cells which perform these func- 
tions he calls phagocytes. The leucocytes are called microphagi, and the 
fixed tissue-cells, which are capable of performing the same function, macro- 
phage Pigment-granules, minute fragments of tissue, and microbes gain 
entrance into a cell, either by the projections which are thrown out by amoe- 
boid cells surrounding and inclosing them (intussusception) or, in the ab- 
sence of amoeboid movements, by a special property of the cells, by which 
they take up into their protoplasm solid particles of various kinds. The cells 
which are known to possess phagocytic properties are the leucocytes, mu- 
cous corpuscles, connective-tissue cells, endothelia of blood-vessels and 
lymphatic vessels, alveolar epithelium of the lungs, and the cells of the 
spleen, bone-marrow, and lymphatic glands. One of MetschnikofPs first 
experiments consisted in introducing under the skin of an insusceptible 
animal — the frog — a fragment of tissue from the liver or spleen of an 
anthracic animal. The implanted piece, when examined a couple of days 
later, was coated with a gelatinous exudation, full of leucocytes. These leu- 
cocytes were charged with bacilli, which he observed to be in various stages 
of degeneration. If the animal was kept at an ordinary temperature no 
harm resulted, but if it was exposed at the time and subsequently to a tem- 
perature of 38° C. the leucocytes, paralyzed by so high a temperature, failed 
in their phagocytic action, the bacilli multiplied, and the frog inevitably 
died. A much more accurate and convincing experiment was made, consist- 
ing in the introduction under the skin of the same animal a membranous 
tube — made of the lining of a species of large grass which grows on the 
banks of rivers (phragmites) — containing spores of bacillus anthracis. Soon 
the little tube filled with lymph, but contained no leucocytes, for to them 



136 



PEINCIPLES OF SURGERY. 



the membrane is impermeable. A similar experiment was made with another 
tube, of which the ends were left open so that leucocytes could enter. In a 
day or two both tubes were examined. The contents of the closed tube 
swarmed with virulent bacilli. In the open tube the spores had been so 
effectually disposed of by the leucocytes that the contents could "be inoculated 
into susceptible animals without effect. Metschnikoff next studied phago- 
cytosis in the tail of the tadpole, and found that the separation of this organ 
at the time this animal is developed into a frog is accomplished by leuco- 
cytes. At the time when the hind legs begin to bud the leucocytes migrate 
into the tail, and at the point where separation is to take place they attack 
the tissues, minute fragments of which may be seen in the interior of their 
protoplasm. In the daphnia, the common water-flea, he studied the destruc- 
tion of a fungus — with which these insects are prone to be infected — by the 




«&o 




Fii 



73.— Phagocytosis. Struggle between Anthrax Bacillus and Leucocyte. A, 
successful phagocytosis; B, unsuccessful phagocytosis. 



microphagi. When phagocytosis proved successful he witnessed the destruc- 
tion of the fungus in the interior of leucocytes; on the other hand, when the 
fungi were present in such large numbers that the leucocytes were unable 
to destroy or digest them, the daphnia died. Next, he investigated phago- 
cytosis in a number of diseases, — erysipelas, anthrax, relapsing fever, and 
tuberculosis. In erysipelas the cocci are first attacked by the leucocytes fill- 
ing the lymph-spaces, and, later, by the fixed connective-tissue cells. In the 
path of destruction he saw leucocytes loaded with cocci, the latter showing 
various stages of dissolution. The connective-tissue cells were also engaged 
in the removal of disintegrated leucocytes. In fatal cases of erysipelas the 
streptococci multiplied with such great rapidity that the phagocytes were 
unable to cope successfully with the disease. Eibbert experimented with the 
spores of aspergillus and mucor, and the results were such that he claimed 
that spores in the interior of leucocytes, the connective tissue of the liver, and 



PHAGOCYTOSIS. 137 

the giant cells which develop in the liver and in the lungs are destroyed, but 
that their destruction is not accomplished so much to phagocytic action of 
the cells as to the exclusion from them of nourishment for the spores, par- 
ticularly of oxygen. Laer injected into the lungs through the trachea 
cultures of the staphylococcus in rabbits, with the result of causing a catar- 
rhal inflammation. The cocci were removed by leucocytes and the em- 
bryonal epithelia of the alveoli. During the first week these cells contained 
many cocci, but during the second week they disappeared in the cells, and 
the animals recovered. 

MetschnikofFs doctrine of phagocytosis has met with violent opposition 
by a number of eminent pathologists, and foremost among them we find 
Baumgarten. In a number of publications this author has taken a positive 
and firm stand against the claim that cells have the power to digest or destroy 
the microbes which inhabit their protoplasm. Holmfeld, Bitter, Prudden, 
and Nuttal have also arrayed themselves against Metschnikoff . With some 
modifications, Klebs is a believer in phagocytosis. In a very interesting paper 
on this subject Osier gives the result of his own observations on the phago- 
cytic action of the cells lining the bronchial tubes and the alveoli of the 
lungs. He shows very conclusively how minute foreign particles are elim- 
inated by means of the phagocytic action of the cells. In connection with 
the subject of inflammation, the doctrine of phagocytosis should be employed 
in a wider sense than was assigned to it by Metschnikoff. In the first place, 
the accumulation of leucocytes at the seat of inflammation must be consid- 
ered in the light of a mechanical barrier: an attempt to protect the tissues 
against infection. Unfortunately, in acute inflammation, this wall is usually 
more apparent than real, as the microbes become diffused through the 
plasma-stream, and are transported by the leucocytes themselves; hence the 
progressive nature of the process. The connective-tissue proliferation proves 
more successful than emigration in limiting the dissemination of microor- 
ganisms in the tissues, as the new cells, so long as they remain attached to 
the matrix which produces them, remain stationary, and mechanically block 
the avenues through which dissemination takes place. It is the impermea- 
ble wall of granulation-tissue that surrounds a suppurating depot which 
finally limits suppurative inflammation. In the next place, the phagocytes 
are scavengers which remove foreign dead particles from the tissues. Lang- 
hans was the first to show that extravasated blood did not simply disintegrate 
and disappear, but that the connective-tissue elements were actively at work, 
and that many of the colored corpuscles disappear in their interior. Eosen- 
berger implanted stained aseptic tissue into the abdominal cavity of animals, 
and, on examining the parts a few weeks later, found that not only had the 
tissues been completely removed by leucocytes, but he was able to follow 
the course of the leucocytes, after they had left the feeding-ground, by col- 



138 PRINCIPLES OF SURGERY. 

ored lines, all of which were seen to radiate from the place where the stained 
tissue had been fixed. In different pathological conditions where tissue- 
proliferation was in process, Klebs could find positive evidence that wan- 
dering cells that had undergone fragmentation had been appropriated by 
the embryonal cells as food, as fragments of the nuclear chromatin of the 
leucocytes could be discovered in the protoplasm of the new cells. In the 
reparative process which follows the subsidence of inflammation a great 
deal of cellular debris is to be removed, and this work is performed by the 
phagocytes, notably by the fixed tissue-cells in a state of proliferation. The 
vegetative capacity of the cells is augmented by the reception into their 
protoplasm of nutritive material furnished them by cells which have suc- 
cumbed in the struggle. Metschnikoff believed that the destruction of 
microorganisms in the interior of phagocytes was an active process, and that 
the protoplasm had a sort of digestive action upon them. To prove the cor- 
rectness of this supposition he made some experiments with the bacillus of 
tuberculosis. He injected a pure culture of the bacilli into the subcutaneous 
tissue of white rats, and, later, produced artificially suppuration at the seat 
of injection. Two months later he found bacilli in the pus-corpuscles in an 
unchanged condition, and without having lost their power of reproduction. 
As in other experiments he had witnessed the destruction and disappearance 
of the same bacillus in living cells, he concluded that phagocytosis is an 
active process which can only take place in a living cell, and is suspended 
with the death of the cell. In mouse-septicaemia and in gonorrhceal pus 
many of the leucocytes are stuffed with microbes, while ethers do not con- 
tain a single bacterial cell: a condition which would tend to prove that the 
bacterial contents in each leucocyte were the offspring of a single microbe, 
and could be advanced as an argument against the phagocytic action of the 
leucocytes. On the other hand, the bacilli in the interior of leucocytes in 
anthracic animals present evidences of degeneration, which speaks in favor 
of the phagocytic theory. 

In 1890 Metschnikoff summarized, at the close of a lecture on this sub- 
ject, his convictions as follows: "It is not possible at the present time to 
state fully and accurately all those influences which are associated in aiding 
phagocytic action, but already we have the right to maintain that, in the 
property of its (the blood) amoeboid cells to include and to destroy microor- 
ganisms, the animal body possesses a formidable means of resistance and 
defense against these infectious agents." 

There are a few at this time who regard the destruction and disappear- 
ance of microbes in phagocytes as an act of digestion. If, however, microbes 
in the interior of phagocytes are rendered harmless or disintegrate and dis- 
appear, this fact is an important one, and it is immaterial in what way this 
result is obtained, whether the microbes are digested by the protoplasm, or 



IMMUNITY. 139 

whether some chemical substance in the cell-body exerts an inhibitory effect 
upon them, or, finally, whether for want of a proper nutrient material they 
are starved, as it were. The results of experimental research have furnished 
positive evidence that infective processes terminate most favorably where 
the conditions described as phagocytosis are accomplished most satisfactorily. 
In all acute inflammatory processes the number of white corpuscles in the 
blood is invariably increased, and they take an active part in destroying the 
microbic cause of the original affection. 

When the struggle between a microbe and a phagocyte turns out in 
favor of the latter, the microbe does not multiply in the protoplasm, or ceases 
to do so before the protoplasm is destroyed, and, as the microbe cannot leave 
without dissolution of the cell, it remains within its narrow confinement and 
is destroyed, either by some as yet unknown chemical substance or dies from 
starvation; in either event the vitality of the cell is not impaired, and the 
microbe disintegrates and disappears. (Fig. 73, A.) If the conditions for 
the growth and development of the microbe in the protoplasm of the cell 
are more favorable, intracellular multiplication of the microbe takes place, 
the toxins which are eliminated produce coagulation-necrosis in the pro- 
toplasm, the cell disintegrates, and the intracellular culture is liberated in an 
active condition. (Fig. 73, B.) In cases of unsuccessful warfare of the 
phagocytes against invading microorganisms, the mechanical obstruction 
composed of emigration corpuscles and embryonal cells is broken down, and 
the rapid increase of microorganisms at the seat of inflammation gives rise 
to extensive local and often general infection. From a practical stand-point 
it can be said that all therapeutic measures which influence favorably the 
process of phagocytosis, in the broadest meaning of this word, are calculated 
to exert a potent influence in arresting or limiting infective processes. 

IMMUNITY. 

In opposition to Metschnikoff, Buchner, Denys, and many followers 
believe that the destruction of bacteria within the body is effected by the 
bacteria-destroying elements which are always present in the blood outside 
of the body. These differences of opinion are being modified by the results 
of clinical observation and experimental research. Metschnikoff himself is 
now of the opinion that the fluids of the body contain also some bacteria- 
destroying properties, but he maintains that they are derived from the liv- 
ing broken-down leucocytes; and Buchner now takes the ground that the 
alexins are derived from the living leucocytes which secrete them. Meltzer, 
of Xew York, advances the idea that one of the resisting powers to infectious 
diseases is plasmolysis, as he believes that the organisms remain in the hy- 
pertonic animal fluid for some time, the state of plasmolysis becomes per- 



140 PRINCIPLES OF SURGERY. 

manent, and the bacteria succumb steadily either to the effects of the plas- 
molysis itself or some insignificant accidental injury. By the observations 
of Adami and other investigators we might consider it as an established fact 
that the interior of the body is regularly invaded by bacteria, which, how- 
ever, do not localize, but are somewhat later destroyed. The successful em- 
ployment of some of the antitoxins in the prevention and cure of certain 
infectious diseases is conclusive proof of the existence of other agencies 
besides phagocytosis in counteracting the effect of pathogenic microbes. It 
appears to be an established fact that the effective antitoxins combine with 
the toxins and form harmless compounds. The view that antitoxins act 
indirectly by stimulating or immunizing living cells seems to be losing 
ground. The combination which the antitoxins enter into with their re- 
spective toxins is not exactly comparable to those of an acid with an alkali, 
because it is a much slower one, but it is one which, as suggested by Ehrlich, 
resembles the formation of a double salt. In reference to the duration of 
immunity, Hansom's experiments made in Ehrlich's laboratory show that a 
kindred serum is longest retained, but that alien serums are not all dis- 
posed of with the same rapidity. Behring speaks of active and passive im- 
munization, but not of active (treatment with toxin) and passive immunity 
(treatment with antitoxin), since in whichever of the two ways it is pro- 
duced the resulting hematogenic immunity is the essential fact. Horses 
made immune with horse-serum retain their immunity scarcely less long 
than is the case with animals made isopathically immune. 

CHRONIC INFLAMMATION. 

Chronic inflammation differs from the acute form only in degree. The 
vascular changes which have been described come on slowly, and are never 
so marked as in acute inflammation; and on this account the emigration 
of blood-corpuscles occurs slowly, and in some instances it is entirely want- 
ing. The inflammatory product is largely, and in some cases exclusively, 
composed of embryonal cells derived from fixed tissue-cells. The noxce 
which excite chronic inflammation are such that exert their deleterious effect 
more on the tissue-cells directly than the capillary vessels. Their primary 
action on the tissues consists in increasing the vegetative capacity of the 
cells; hence, mature cells are transformed into embryonal or granulation 
tissue and remain in this condition as long as the noxce exist, and retain their 
pathogenic qualities or otherwise until the new cells undergo retrograde 
metamorphosis. If in a chronic inflammation degeneration of the embryonal 
cells has not taken place, and the primary cause has ceased to act, the new 
tissue is either removed by absorption or is converted into mature tissue, in 
which event the inflammation has resulted in hyperplasia. Syphilitic 



CHRONIC INFLAMMATION. 141 

gummata, which are composed almost exclusively of embryonal tissue, dis- 
appear promptly under a vigorous antisyphilitic treatment; because by such 
treatment the microorganisms which have caused the lesion are either de- 
stroyed or at least have been deprived, for the time being, of their pathogenic 
properties. 

Chronic inflammation is represented by that large class of affections 
which are included under the name granulomata. These swellings, irre- 
spective of their primary microbic cause, are composed of w r hat is known 
as granulation-tissue. Some pathologists have been inclined to classify them 
with tumors because their development is seldom attended by well-marked 
symptoms of inflammation, and in their methods of regional and general 
dissemination they bear a close resemblance to the malignant tumors. Their 
obstinacy to successful treatment does not depend upon any malignant 
qualities of the tissues of which they are composed, but upon the difficulty 
of eliminating or rendering inert the primary cause by internal medication 
or operative procedures. 

All granulomata are inflammatory in their origin, and under the micro- 
scope present all the characteristic appearances of inflammation: Histologic- 
ally they are composed of embryonal cells which correspond to the type of 
the tissues in which or from which they have developed. In a tubercular 
nodule we find giant cells, epithelioid cells, the ordinary granulation-cell, 
and leucocytes. Actinomycotic sw r ellings are composed almost exclusively 
of embryonal connective tissue. Many of the granulomata contain Ehrlichias 
plasma-cells (Mastzellen), of unknown origin, composed of a finely-granular 
mass around a vesicular nucleus. On staining with aniline colors, the 
nucleus remains unchanged, while the granules are deeply stained. The 
cells are about the size of a leucocyte, either spherical or somewhat elongated 
in shape. In some cases the outer portion of the inflammatory product, 
being sufficiently remote from the infected area, is converted into a firm 
connective-tissue capsule, which limits the extension of infection, while its 
interior, from the presence of the specific microorganisms, but probably more 
on account of inadequate blood-supply, the tissues undergo rapid retrograde 
degenerative changes. 

Secondary infection in a granuloma, either through, the circulation or, 
what is more common, from without, through some minute infection-atrium, 
is a not uncommon occurrence. Secondary infection almost always means 
localization of pus-microbes in the granulation-tissue and a breaking down 
of the latter into pus-corpuscles. The serious conseqriences which follow 
suppurative inflammation of a gumma developing after incision made upon 
a wrong diagnosis are well known. Infection of a large tubercular depot 
with pus-microbes after incision without proper antiseptic precautions, or 
after spontaneous evacuation, is followed by destruction of the remaining 



142 PRINCIPLES OF SUKGERY. 

granulations, profuse suppuration, and not infrequently by death from sep- 
sis. Actinomycosis gives rise to a large granuloma without any tendency to 
suppuration until infection takes place with pus-microbes, when the granula- 
tions melt away rapidly, leaving a deep ulcer with ragged, undermined mar- 
gins, and a speedy extension of the combined infective processes, following 
the connective tissue in their course. 

The secondary infection, however, may prove beneficial and become the 
means of complete elimination of the inflammatory product and microor- 
ganisms of the primary infection. In this way a localized tubercular lesion 
is sometimes cured spontaneously by suppuration. A suppurative inflam- 
mation of a tubercular gland of the neck is often followed by complete re- 
moval of the bacilli-containing tissues and a permanent cure. All chronic 
inflammatory processes are attended by recurring attacks of acute exacer- 
bations. If during these attacks in the periphery of the chronically-inflamed 
area a more active cell-proliferation is initiated, the conditions for a more 
successful phagocytosis are improved and the acute attack has proved a 
curative measure. 

The surgeon often resorts to measures which result in the transforma- 
tion of a chronic into an acute inflammation, in imitation of Nature's efforts 
in the same direction. In illustration of this, I will only mention ignipunct- 
ure. The fenestration of a chronic inflammatory swelling under strict anti- 
septic precautions has proved a valuable therapeutic resource by securing 
drainage, but more especially because around each tubular eschar made with 
the needle-point of a Paquelin cautery a zone of active tissue-proliferation is 
created, and the new tissue, by undergoing transformation into cicatricial 
tissue, serves a useful purpose in starving out microbes that have escaped the 
cautery. Another instructive instance of the benefits which accrue from the 
substitution of an acute for a chronic inflammation is found in the use of 
jequirity in ophthalmic practice. The powdered bean or some other prep- 
aration of this drug, when brought in contact with the conjunctiva, pro- 
duces a violent inflammation which has frequently proved a curative measure 
in the treatment of trachoma and some forms of pannus of the cornea. 

One of the ways in which an acute inflammation acts beneficially in 
promoting the process of resolution in tissues the seat of a chronic inflam- 
mation is by its stimulating action on the capillary vessels. The active 
hyperemia may become the means of clearing partially-obstructed capillary 
vessels of implanted colorless corpuscles, and thus remove from the weak- 
ened tissues not only the mechanical causes which have maintained the 
chronic congestion, but also the intravascular cause of the inflammation: 
the microbes. When the infected corpuscles reach the general circulation 
there is a chance for more effective phagocytosis and elimination of the 
microbes through one or more of the excretory organs. 



SYMPTOMS AND DIAGNOSIS OF INFLAMMATION. 143 



SYMPTOMS AND DIAGNOSIS OF INFLAMMATION. 

For practical purposes, inflammation may be divided into acute, sub- 
acute, and chronic, according to trie intensity of symptoms and the time 
required to reach one of its terminations. The nature of the primary cause 
determines the course and nature of the inflammation. The microbes of 
suppuration, erysipelas, anthrax, glanders, tetanus, and gonorrhoea cause 
acute affections, while the microorganisms of tuberculosis, lepra, and actino- 
mycosis cause lesions which are noted for their chronicity. Acute inflamma- 
tion may become subacute and finally chronic, as in suppurative osteomye- 
litis, where, if the disease is multiple, in the first bone affected it pursues a 
very acute course; while often in the successive bones attacked it is less 
intense, and not infrequently in the last bone involved it appears as a chronic 
affection. A chronic inflammation may be followed by a subacute or acute 
attack, as is frequently observed in tuberculosis complicated by secondary 
infection with pus-microbes. In acute inflammation the local and general 
symptoms are so well marked that no difficulties are in the way of recog- 
nizing its existence, and it only remains to decide upon its character. The 
fever which attends the inflammation is only a symptom, and indicates the 
introduction into the general circulation of phlogistic substances from the 
products of exudation or the fixed tissue-cells which have undergone patho- 
logical changes. Microbes that cause acute inflammation differ greatly as 
to the amount or intensity of action of the phlogistic substances which they 
produce in the inflamed tissues affected; also exert an important influence 
in modifying the febrile disturbance. Suppuration caused by the micro- 
coccus pyogenes tenuis is not attended by so high a temperature as when 
produced by the staphylococcus or streptococcus. The rise in temperature 
which accompanies inflammation is due either to the introduction into the 
circulation of fibrin-ferment resulting from the destruction of leucocytes or 
the production of toxins by the specific action of microbes on the tissues, 
which act as phlogistic substances when introduced into the general circula- 
tion: a fact which has been abundantly demonstrated by clinical observation 
and experimental research. As soon as the causes which have produced the 
rise in temperature in inflammation have been rendered inert by phagocyto- 
sis, or have been eliminated with the removal of the inflammatory product, 
the fever subsides. The general disturbances, such as headache, vomiting, 
loss of appetite, thirst, and the ever-present feeling of lassitude which attends 
acute inflammation of all kinds, are caused by the fever and the presence 
of toxic substances in the blood. The symptoms of inflammation, which 
have be^n described at length, must be studied separately and conjointly 
in each form of inflammation, and their individual and mutual significance 
carefully estimated. A local rise in temperature is of more diagnostic value 



144 PRINCIPLES OF SURGERY. 

in ascertaining the existence of inflammation than fever, as the latter can 
be caused by the absorption of fibrin-ferment from any causes which destroy 
the colorless blood-corpuscles and the absorption of the products of tissue- 
disintegration in malignant tumors; while a permanent increase of the tem- 
perature at the seat of the disease denotes almost infallibly the existence of 
inflammation. In reference to the extension of the inflammatory process, 
it can be said that this will be influenced by the anatomical structure of the 
part inyolyed and the manner of diffusion of the microbe which causes the 
inflammation. If a mucous or serous surface is affected, infection is prone 
to spread rapidly by continuity of tissue and the mechanical dissemination 
of the microbes on the surface in the mucous secretion, and by the move- 
ments of one serous surface upon the other. In erysipelas the inflammation 
spreads rapidly, as the microbe is diffused through the lymphatics and con- 
nective-tissue spaces. In phlegmonous inflammation the pus-microbes find 
no mechanical barriers, and are rapidly distributed over a larger area through 
the connective-tissue spaces. The same manner of diffusion is observed in 
anthrax if the bacillus finds ingress into a part supplied with an abundance 
of loose cellular tissue, while the disease remains circumscribed and presents 
itself in an indurated form if it is located in tissues which do not present 
such favorable anatomical conditions for extension of the local invasion. 
The nature of the inflammatory product always answers to the specific 
action of the microbe in the tissues which caused the inflammation. Thus, 
an inflammation caused by pus-microbes will result in the formation of pus; 
while the microbes which produce chronic inflammation, as a rule, only con- 
vert the preexisting mature into embryonal tissue. The microbes which 
have a short existence in the tissues may give rise only to intense hyper- 
emia and a moderate emigration of the colored blood-corpuscles, as, for 
instance, the streptococcus of erysipelas, The genuine, uncomplicated ery- 
sipelatous inflammation is of such short duration that perfect restoration 
of the parts is accomplished in a few days. 

PROGNOSIS. 

The most favorable termination of inflammation is resolution, with 
restitutio ad integrum of structure and function of the tissues which were 
the seat of the inflammatory process. Eesolution is only possible if the emi- 
gration of blood-corpuscles is moderate in quantity and none of the cellular 
elements of the exudate are transformed into pus-corpuscles. If exudation 
take place rapidly, the connective-tissue spaces are completely blocked 
with the emigration-corpuscles and the products of coagulation-necrosis, 
which seriously impairs or completely arrests plasma-circulation, and. by 
pressure upon the blood-vessels, may interfere with the capillary circulation 
to snch an extent as to cause necrosis. Eesolution, as has been previously 



PROGNOSIS. 145 

stated, signifies that, after subsidence of the symptoms of inflammation, the 
part is left in a condition capable of removing the inflammatory product and 
of repairing the damage done. Many of the leucocytes which have retained 
their vitality immigrate back into the general circulation either through the 
walls of capillaries or, what is more frequent, through the lymphatic system. 
The remaining leucocytes and colored corpuscles undergo degeneration and 
are removed by absorption. Fibrin which has formed in the tissues is trans- 
formed into a granular mass and is removed in a similar manner. Embryonal 
cells which have become detached, or have been damaged by the inflamma- 
tion, are also removed by absorption after they have undergone granular 
degeneration. The transudation is removed by absorption as soon as capil- 
lary circulation is restored and the connective-tissue spaces have been cleared 
of their cellular contents. The capillary wall is repaired, and any tissue- 
defects are restored by proliferation of the fixed tissue-cells. The inflam- 
matory exudate may prove a source of danger when, by its mechanical press- 
ure, it interferes with the function of important organs, as the brain, heart, 
or lungs. A moderate transudation within the skull from inflammation 
of any of the meninges can produce death from compression of the brain; 
a pericardial effusion, when sufficient in amount to interfere mechanically 
with the action of the heart, causes death by syncope; and a copious effusion 
into the pleural cavity, especially if it come on rapidly, may impair respira- 
tion to such an extent as to result in death from apncea. A slight croupous 
exudation upon the vocal cords or oedema about the entrance to the larynx 
destroys life by preventing, in a purely mechanical way, the entrance into 
the lungs of an adequate quantity of air. Inflammation is greatly modified 
by the age and general condition of the patient. Infants and persons ad- 
vanced in years possess little power of resistance, and, when attacked by in- 
flammation, the disease is prone to become diffuse and lead to serious patho- 
logical changes. The same can be said of persons who have been debilitated 
by antecedent diseases or intemperate habits. The greatest danger in the 
different forms of inflammation, as far as life is concerned, consists in the 
introduction into the general circulation of septic material produced in the 
inflamed part by the action of microbes on the tissues. This general infec- 
tion, occurring in the course of a localized inflammation, appears either as a 
symptomatic fever, which disappears with the subsidence of the local process, 
or as a progressive septicaemia, pyaemia, or septico-pyaemia. The latter dis- 
eases will be considered in separate chapters. Tubercular affections are al- 
ways attended by the danger incident to extension of the process to other 
organs by dissemination of bacilli through the lymphatic channels or blood- 
vessels. Chronic suppuration Anally causes amyloid degeneration of im- 
portant organs, and death ensues from this cause. In summing up what has 
been said under this head, it is evident that the prognosis rests mainly upon 



146 PRINCIPLES OF SURGERY. 

the intrinsic pathogenic qualities of the microbe which has caused the in- 
flammation; the anatomical structure, location, and physiological impor- 
tance of the part or organ inflamed; the general condition of the patient, 
and the accessibility to and feasibility of treating the disease by direct radical 
surgical intervention. 

TREATMENT. 

As inflammation per se is no disease, but an effort on the part of the 
organism and the tissues affected to eliminate or render harmless the pri- 
mary cause, the treatment must be, in each individual case, purely symptom- 
atic. A proper appreciation of the nature and tendencies of inflammation 
is an essential prerequisite to rational treatment. In surgery the prophy- 
lactic treatment of inflammation is the most important and satisfactory. 
The prevention of inflammation in accidental and operation wounds by 
strict antiseptic and aseptic precautions has made modern surgery what it is. 
The surgeon has it now in his power, by resorting to antiseptic measures, to 
prevent the innumerable and formerly too often fatal wound complications. 
Lister has inaugurated a new era in surgery, and his work, as well as that of 
his early enthusiastic followers, has been the means of saving annually thou- 
sands of lives. The mortality of even the most desperate operations, where 
the antiseptic or aseptic treatment can be followed to perfection, has been so 
much reduced that operative surgery has received a new impetus, and opera- 
tions are devised and put in practice almost daily which formerly would have 
been looked upon as a freak of imagination or the outcome of a diseased 
brain. The prophylactic treatment of inflammation in dealing with wounds, 
or other avenues through which infection can take place, consists in securing 
for the place deprived of the effective protection against the entrance of 
pathogenic microorganisms — the intact skin or mucous membrane — an asep- 
tic condition by antiseptic measures, and to bring in contact with it only 
things that have been thoroughly sterilized. 

In inflammation without an external tangible infection-atrium we must 
take it for granted that microbes have entered the circulation through slight 
defects the existence of which, perhaps, the patient does not remember, and 
which have left no appreciable marks of their former existence, or infection 
has taken place through some of the appendages of the skin or through a 
mucous membrane, with localization of the microbes in a part or organ pre- 
viously prepared for their reception and growth; that is, in a location pre- 
senting a locus minoris resistentice. 

Eecognizing the fact that inflammation, wherever it occurs, is produced 
by the action upon the vessel-wall and the tissues outside of it of specific 
microorganisms, it would appear that the most rational indication for treat- 
ment would be to resort to such means as would destrov the microbes in the 



TREATMENT. 



147 



tissues as soon as their presence is manifested by their action. This would 
imply the saturation of the inflamed tissues with germicidal solutions, which 
from Laboratory experiments are known to be effective in destroying, or at 
Least inhibiting the growth of, such microbes; hence, it has been advised to 
resort to 

Parenchymatous Injections. — This method of treatment was strongly 
advised and extensively practiced by Hneter long before the direct relation- 
ship between certain microbes and definite forms of inflammation had been 
demonstrated. Hueter claimed that every inflammation was caused by cer- 




Fig. 74.— Hueter's Infusor. 



tain noxce introduced from without, and which he aimed to destroy by satu- 
rating the inflamed tissues with an antiseptic solution. His favorite remedy 
was a 3- to 5-per-cent. solution of carbolic acid. The instrument which he 
used was an ordinary Pravaz syringe, with a long needle provided with a 
number of small lateral openings. In adults he injected as much as 10 
grammes at a time of a 3-per-cent. solution. In using this method in the 
treatment of large, granulating, tubercular foci he employed what he termed 
an infusor, composed of a graduated glass cylinder, joined with the needle 
by means of a rubber tube. By this method of injection the fluid diffused 
itself through the soft, granular mass by its own weight. In the treatment 



148 PRINCIPLES OF SURGERY. 

of tubercular lesions Hueter claimed for the parenchymatous injections of 
carbolic acid great curative powers. Eational as this method of treatment 
appears, it has not yielded the results that were anticipated. The living tis- 
sues cannot be compared with a test-tube. Nitrate of silver, iodine, perman- 
ganate of potassa, corrosive sublimate, alcohol, and other potent germicidal 
agents have been used since, but the results, on the whole, have been any- 
thing but satisfactory. If this method of treatment is to be successful in the 
treatment of acute inflammation, it must be instituted at an early stage, at a 
time when only a limited area of tissue has been infected, as, under such cir- 
cumstances, if the area of infection could be accurately outlined, it would be 
possible to saturate the tissues with an antiseptic solution without running 
the risk of killing the patient by administering a toxic dose of the drug em- 
ployed, which might be the case if a larger area were treated in a similar 
manner. If we remember that the microbes are diffused throughout the 
entire exudation and constitute the most important element of the inflam- 
matory product, it is easy to understand that sterilization of the inflamed 
tissues by means of parenchymatous injections is not an easy task, and we 
are then in a position to realize why this method of treatment has not proved 
more uniformly successful. Most of the germicidal agents heretofore em- 
ployed in this manner, when brought in contact with the tissues, form com- 
pounds which prevent further diffusion, and therefore each needle-puncture 
sterilizes only a very small portion of the inflamed district. It is possible 
that in the future non-toxic, but at the same time effective germicidal, sub- 
stances will be discovered which can be used in larger quantities, and in this 
event the treatment of inflammation by parenchymatous injections will have 
a wide range of application, and will be practiced with better success. At 
present this method has a limited field of usefulness in the treatment of 
the various forms of inflammation. Under no circumstances should the 
amount of the drug used exceed the dose which it would be safe to admin- 
ister internally, and the danger of a poisonous dose should be remembered 
in repeating the injection. An ordinary hypodermic syringe with a long 
needle can be used in making the injection. That the needle and syringe 
should be perfectly aseptic is to be understood as a matter of course, as un- 
clean instruments have often been the means of conveying a fatal disease. 
Multiple punctures are to be preferred, as in this manner, by using the same 
amount of fluid, more tissue can be saturated than by a single puncture. 
Before making the punctures the surface must be disinfected. The object 
should be to bring the antiseptic solution in contact with as much of the 
infected tissues as possible, and if the disease manifests a tendency to spread 
it is advisable to go beyond the zone of infection, as, for instance, in cases 
of erysipelas and anthrax. A 5-per-cent. solution of carbolic acid is prefer- 
able to all other antiseptics in the treatment of acute inflammatory affections 



T UK AT MK NT. 149 

by this method. Many accessible tubercular affections arc greatly benefited 
by parenchymatous injections of carbolic acid. Recently, intraarticular and 
parenchymatous injections of iodoform have been strongly recommended in 
the treatment of articular and other forms of surgical tuberculosis. 

Antiphlogistic Treatment. — An erroneous conception of the nature and 
tendencies of inflammation has for centuries induced the ablest teachers 
and practitioners to advocate and practice what they termed the anti- 
phlogistic treatment of inflammation. This included blood-letting, cupping, 
leeching, and the internal use of emetics and cathartics. It was urged that 
as inflammation is attended by an increase of heat, swelling, and redness, 
such remedies should be employed as w r ill reduce arterial tension. Venesec- 
tion is now seldom, if ever, resorted to in the treatment of any form of in- 
flammation. An unimpaired vis a tergo is one of the best means to prevent 
stasis within the inflamed capillaries, and practical experience has shown 
that all remedies and agents which diminish the intraarterial tension only 
diminish the prospects for a favorable termination of the inflammation. 
Cohnheim showed experimentally that the threatened stasis in the exposed 
mesentery of the frog was avoided by injecting into one of the veins 1 
centimetre of a 6-per-cent. solution of sodic chloride. If, under similar con- 
ditions, a considerable quantity of blood is abstracted, the congestion can be 
seen to terminate in a short time in complete stasis. While venesection in 
the treatment of inflammation has been discarded, the direct abstraction of 
blood from the inflamed part has proved a useful therapeutic resource. 
Xancrede divided a large vein on the distal side of the circulation in the 
tongiie of a frog, the seat of an intense inflammation artificially produced. 
He describes the tangible therapeutic effect as follows: "The effect upon the 
obstructed vessels was first an oscillation of the blood-disks, then an occa- 
sional momentary flow of blood, then suddenly a rapid resumption of the cir- 
culation, sweeping out the blood-vessels and apparently restoring them to 
their normal condition, except at spots where the agents inducing inflam- 
mation had chemically destroyed the vessels or coagulated their contents." 
Genzmer showed that in the inflamed mucous membrane of a frog scarifica- 
tion hastened resolution. In order to be of benefit the scarification must 
be made through the inflamed part, so as to unload directly the dilated and 
engorged capillary vessels, and on this account this method of treatment is 
only applicable when the inflammation is superficial and affects accessible 
parts. Leeches should never be used, as infection from this source has fre- 
quently resulted disastrously. The scarificator used for cupping is difficult 
to keep aseptic, and the number and depth of the scarifications to be made 
are not under the control of the surgeon, and for these reasons this instru- 
ment has only an historical interest and antiquarian value. The scarification 
should be made with a sharp scalpel, and the bleeding encouraged by apply- 



150 PRINCIPLES OF SURGERY. 

ing warm water. Scarification is followed by great relief in inflammation 
of accessible mucous membranes, and has recently been very strongly recom- 
mended in the treatment of erysipelas for the purpose of preventing the ex- 
tension of this disease. 

In the different forms of septic inflammation attended by severe gen- 
eral symptoms the gastrointestinal canal often participates in the process, 
and vomiting and diarrhoea become conspicuous and often distressing symp- 
toms. These symptoms should not be checked, as they indicate an attempt 
on the part of the organism to eliminate through the gastrointestinal 
mucous membrane microbes and toxins which have reached it through the 
general circulation. The surgeon should assist this effort by administering 
a few doses of calomel, followed by a saline cathartic, which will often con- 
trol the vomiting and diarrhoea more promptly by removing the cause than 
medicines employed to arrest the process of elimination. 

Physiological Rest. — One of the most urgent indications in the treat- 
ment of inflammation is to secure for the part affected a condition approach- 
ing physiological rest. In ulcerative affections of the gastrointestinal canal 
the patient should abstain from taking food by the stomach. Fixation of 
the chest by means of broad strips of adhesive plaster affords great relief in 
pleuritis. An inflamed joint must be immobilized by some kind of a splint. 
A chronic cystitis usually yields to suprapubic or perineal drainage of the 
bladder after all other measures have failed. In inflammatory affections of 
the eye exclusion of light is one of the most essential features of successful 
treatment. Patients suffering from inflammatory affections of the tonsils, 
pharynx, and larynx should use their voice as little as possible. In cases of 
acute inflammation of the brain or its envelopes the patient must be kept in 
a dark room, and absolute quietude enforced. 

Elevation of Inflamed Parts. — From the diminished vis a tergo on the 
distal side of the capillary vessels, venous engorgement is as pronounced 
as increased arterial tension on the proximal side of the inflamed capillary 
vessels, and elevation of the inflamed part improves the vascular disturb- 
ances by the force of gravitation favoring the return of venous blood. The 
importance of elevation of the inflamed part becomes manifest in the treat- 
ment of inflammatory affections of the extremities. In phlegmonous inflam- 
mation of the hands or feet the throbbing pain is always aggravated if the 
limb is kept in a dependent position, and promptly relieved upon placing 
it in an elevated position. Elevation not only alleviates the pain, but is at 
the same time the most effective means of removing the oedematous swelling. 
If necessary, elevation can be combined with suspension in order to secure 
more perfect rest for the inflamed part. In severe acute inflammation it is 
not only necessary to secure rest for the part inflamed, but of the whole body, 
and in such cases the patient must observe the recumbent position in bed, 



TREATMENT. 



i:>l 



as all muscular movements and all unnecessary >train upon the blood-v se a 
cannot but be productive of harm by favoring the ingress into the circula- 
tion of microorganisms and their toxins from the seat of inflammation, 
or. perhaps, result in embolism from detachment of a portion of a thrombus: 
an accident which possibly might not have occurred otherwise. 

Application of Cold. — Cold has been resorted to indiscriminately and 
empirically in the treatment of inflammation. Cold is a potent agent for 
good or harm, according to the stage of inflammation during which it is 
employed. The sensation of heat, both subjective and objective, naturally 
sue^ested the use of this remedy. The application of cold is of great benefit 
during the earliest stage of inflammation, at a time when exudation is only 
beginning and the capillary vessels are dilated and only partially obstructed. 







Fig. 75.— Cold Coil. (After EsmarcJt.) 

Cold, when applied under these circumstances, becomes a valuable remedial 
agent (1) by producing contraction of the small blood-vessels; (2) by pro- 
ducing at least an inhibitory effect upon the microorganisms in the inflamed 
tissues. The contraction of blood-vessels which takes place under the appli- 
cation of cold has a tendency to clear the capillaries of their contents and to 
prevent further mural implantation. Microorganisms can only multiply at 
a certain temperature, and if this can be kept at a point low enough to pre- 
vent their increase in the tissues by the application of cold this agent fulfills 
one of the causal indications in the treatment of inflammation. If, however, 
stasis has already taken place in the capillaries first affected, the application 
of cold will prove harmful, as it will tend to prevent the formation of an 
adequate collateral circulation. Cold acts most beneficially when the in- 



152 



PRINCIPLES OF SURGERY. 



flammation is located in the superficial parts, but its prolonged use will reach 
even deep-seated structures, as the pleura, peritoneum, the brain and its 
envelopes, the joints and bones. When it appears desirable to resort to the 
use of cold, this remedy should be applied in the form of an ice-bag or cold 
coil. The part to which the ice-bag is to be applied can be covered with 
several layers of a wet towel, as otherwise the prolonged use of the direct 
application of ice may freeze the skin. The sensations of the patient can 
usually be taken as a safe guide as to the length of time it should be con- 
tinued. 

Antiseptic Fomentations. — The ordinary filthy poultice of flaxseed, 
slippery elm, or bread and milk has now no place among the resources of 




Fig. 76.— Cold Coil for the Head. (After Letter.) 

the aseptic surgeon. The common poultice is a hot-bed for bacteria, and, 
as such, it should be discarded. In the treatment of an ordinary furuncle 
with poultices, I am sure that almost every surgeon must have seen occa- 
sionally the development of innumerable minute daughter-furuncles on the 
surface covered by the poultice. In phlegmonous inflammation of the 
fingers or hand the prolonged use of the poultice is followed by maceration 
of the skin, extensive oedema of the superficial structures, a flabby condition 
of the granulation, — in fact, all the evidences which point to the poultice as 
a means of favoring the extension of the infective process. When inflam- 
mation has passed beyond the stage where cold exercises a favorable influ- 
ence, or where cold applications increase the suffering, warm antiseptic 



TREATMENT. 153 

fomentations should be employed. The surface to which they are to be ap- 
plied should be thoroughly cleansed with warm water and potash-soap. The 
antiseptic solution to be used should be selected according to the age of the 
patient or the area affected, with a special view of guarding against the ab- 
sorption of a toxic dose of the drug employed. Acetate of aluminum, in the 
strength of 1 per cent, dissolved in sterilized water, is a safe preparation 
under all circumstances. Boric and salicylic acids are efficient and safe prep- 
arations. Greater care is necessary in the use of carbolic acid and corrosive 
sublimate, as, when concentrated solutions of these drugs are used for any 
length of time in infants, the aged, or persons suffering from organic disease 
of the kidneys, there is danger of poisoning from absorption through the 
intact skin. In children and marantic persons it is safer to use acetate of 
aluminum, salicylic or boric acid, and reserve the more potent antiseptics 
for adults suffering from circumscribed inflammatory lesions. Hot fomenta- 
tions act as derivatives and favor the formation of collateral circulation; at 
the same time they relieve pain. A number of layers of hygroscopic gauze 
or flannel cloth are wrung out of one of these antiseptic solutions and applied 
over the affected part, and for the purpose of retaining the heat and of pre- 
venting evaporation of the solution the compress is to be covered either with 
gutta-percha, rubber sheeting, or macintosh cloth, and the dressing is re- 
tained by an appropriate bandage. The compress is removed two or three 
times a day, again wrung out of the hot solution, and reapplied as before. 
Absorption through the skin of the antiseptic substance used may have a 
direct influence in diminishing the intensity of the cause which produced 
the inflammation, and prepares, in an admirable manner, the field for any 
operation which may become necessary later. As local applications alcohol 
and some of the silver preparations have recently been strongly recom- 
mended in preventing suppuration, and both of them have been found very 
efficient. The unguentum Crede has had a very extensive trial. 

Antipyretics. — If the rise in temperature which attends many of the 
acute inflammatory affections is due to the introduction into the circula- 
tion of phlogistic substances which are produced by the action of the micro- 
organisms in the inflamed tissues, it is not difficult to conceive that its arti- 
ficial reduction by the internal use of chemical substances is not followed by 
any permanent benefit. The rational treatment of the fever consists of such 
local measures as will remove its cause. Antifebrin, antipyrin, salicylated 
soda, quinine, and other antipyretic drugs, when employed in large doses 
will usually reduce the temperature several degrees for a few hours, but this 
is always accomplished at the expense of the forces which are laboring to 
clear obstructed paths, and on this account their use, on the whole, has 
resulted in more harm than good to the patient. Quinine is the least ob- 
jectionable of the drugs which have been mentioned, and in the beginning 



154 PRINCIPLES OF SURGERY. 

of an inflammation, by its known tonic effect on the small blood-vessels, 
when administered in a large dose, has a favorable effect in preventing rapid 
dilatation of and stasis within the capillary vessels. If used at all, it should 
be given in a decided dose, — 1 gramme, in solution, — immediately or soon 
after the development of the first symptoms. Sponging the surface of the 
body with warm water and the use of warm baths are the most rational anti- 
pyretics, as these" simple measures do not weaken the heart's action, while 
they have a decided effect on the temperature, and at the same time add to 
the comfort of the patient and favor the elimination of microbes through 
the excretory organs of the skin. As the kidneys are known to eliminate 
microorganisms that reach them through the general circulation, their func- 
tion should be carefully inquired into, and if the secretion of the urine is 
scanty, diuretics, like liquor ammoniae acetatis or acetate of potash, should 
be given. 

Stimulants. — Just as soon as symptoms of sepsis develop in the course 
of an inflammation, alcoholic stimulants should be freely administered to 
meet in time the dangers incident to heart-failure. Stimulants have largely 
taken the place of antiphlogistics at the present time in the treatment of 
septic inflammations. Brandy, cognac, or whisk}', not. in measured doses, but 
given in quantities large enough to produce the desired effect on the heart, 
are given at intervals of one or two hours. Champagne is a more diffusible 
stimulant, and is to be resorted to when the stomach does not tolerate other 
alcoholics. In chronic cases Tokay or Greek sherry is to be preferred. In 
wasting diseases a good quality of beer, ale, or porter will do excellent serv- 
ice. In cases where, from any cause, the heart's action is suddenly dimin- 
ished, strychnine, camphor, or musk can be administered subcutaneously to 
bridge over the time for the employment of more substantial stimulants. 

Diet. — The treatment of inflammation by starvation has been abolished 
long ago. The strength of the patient must be sustained in time by a nutri- 
tious, well-selected diet. Animal broths, beef-tea, and milk should be freely 
given from the very beginning, and if more substantial food can be digested 
it should not be withheld. Oysters, eggs, finely-scraped raw meat or rare 
roast are excellent articles of food for patients whose strength is being un- 
dermined by debilitating, suppurative affections. If the stomach does not 
retain food, the patient should be nourished by rectal enemata of peptonized 
milk and beef-tea in quantities not exceeding 4 ounces, given alternately, 
every eight hours. Eipe oranges and grapes are most always grateful to the 
patient, and their use should never be prohibited, unless the gastrointestinal 
canal is the seat of inflammation. In the treatment of acute inflammatory 
affections of the peritoneum and the gastrointestinal canal stomach feeding 
must be suspended, and if need be, rectal enemata should take its place. 

Tonics and Alteratives. — In protracted inflammatory affections tonic 



TREATMENT. 155 

doses of quinine are indicated. Tincture of chloride of iron is an excellent 
remedy a It cm- the acnte febrile symptoms have subsided. Under similar cir- 
cumstances one or more of the bitter tonics can be given with benefit if the 
appetite is defective. If there is any history of specific disease, a thorough 
antisyphilitic treatment will often produce a marked effect for the better 
on the inflammatory process. Catarrhal inflammation in rheumatic patients 
is favorably influenced by antirheumatic remedies. Syphilitic lesions are to 
be treated by potassic iodide and small doses of corrosive sublimate. Tuber- 
cular affections call for guaiacol, arseniate of iron, syrup of iodide of iron, 
and, if the patient's stomach can tolerate it, pure codliver-oil. The latter 
drug should be given alone, and not in emulsion, in gradually-increasing 
doses an hour and a half after each meal. 

Anodynes. — Eemedies to relieve pain must always be used with caution, 
as in painful chronic affections their prolonged use frequently engenders a 
habit. The cause of pain must be sought for, and, if possible, removed by 
local measures. In acute inflammation pain indicates tension in the in- 
flamed part, and prompt relief is obtained by subcutaneous or open incision. 
Periostitis and paronychia should be treated by this method. In superficial 
inflammations scarification answers the same purpose. If opiates are used, 
a decided dose is better than smaller doses frequently repeated. The ano- 
dyne effect of opium is increased by the addition of a minute dose of atro- 
pine.. Chloral and potassic bromides are to be preferred to opium to relieve 
the pain of intracranial lesions. Phenacetin in 1 / 2 -gramme doses is a very 
excellent anodyne in cases of peripheral neuritis. Inhalations of chloroform 
to allay intense pain should never be resorted to except by the direction of 
and under the personal supervision of a competent physician. Local appli- 
cations of anodynes are often effective in the treatment of superficial inflam- 
mation and neuralgic affections. Chloroform liniment and menthol are most 
frequently prescribed for this purpose. 

Massage. — In chronic inflammatory affections systematic massage, 
scientifically practiced, is an exceedingly important and valuable therapeu- 
tic resource. It stimulates the surrounding vessels to increased action, and 
exerts a potent influence in restoring the normal circulation in the affected 
capillary vessels, and always promotes absorption. The masseur should be 
instructed to apply some absorbent preparation before making the manipula- 
tions, as the endermic use of absorbent drugs in this manner will increase 
the efficacy of the treatment. A drachm of potassic iodide or half a drachm 
of iodoform to an ounce of lanolin will be an excellent preparation for this 
purpose. Cold and hot douches, passive and active motion, combined with 
massage, will often expedite a cure. 

Counter-irritation. — Like so many other time-honored methods of treat- 
ment, counter-irritation in the treatment of acute inflammation has almost 



156 PRINCIPLES OF SURGERY. 

entirely gone out of use. In chronic inflammation, blistering and painting 
with the tincture of iodine will at least satisfy the patient, if no good result 
from them; and if he do not recover, he is at least prevented from passing 
into the hands of charlatans until the time has arrived to resort to more 
effective and radical measures. Kocher praises the application of the actual 
cautery in the treatment of chronic tubercular osteomyelitis and synovitis. 
The seton and moxa have fallen into well-merited disuse for all time to 
come. 

Ignipuncture. — In many chronic affections, where the inflammatory 
exudation remains stationary for a long time, multiple punctures with the 
needle-point of a Paquelin cautery, made under strict antiseptic precautions, 
will have a prompt effect in mitigating the primary cause, as well as in 
promoting absorption. 



CHAPTER VI. 

Pathogenic Bacteria. 

Bacteria, microorganisms, microbes, and germs are synonymous 
terms for certain minute, microscopical, vegetable organisms which, when 
introduced into the living body, produce the fever and the tissue-changes 
described in the preceding chapter. For a time it was claimed that these 
minute organisms belonged to the animal kingdom, as some of them were 
seen to possess spontaneous movements; but now it is generally agreed that 
they are minute plants, and botanists have made great progress in perfecting 
a scientific classification. Among the men who have developed this part of 
botany, the names of Cohn, Zopf, and Nageli stand preeminent. 

CLASSIFICATION. 

The pathogenic bacteria which will claim our attention belong to the 
class known as schizomycetes (Spaltpilze). In diameter they vary from 
0.001 to 0.004 millimetre, and are composed largely of an albuminoid sub- 
stance called by Nencki mycoprotein. Toward the periphery this substance 
becomes firmer, and forms a gelatinous envelope, a sort of a membrane, 
which is said to contain cellulose, and, in some instances, even fatty material. 
The outer surface of bacteria is frequently covered with a viscid substance, 
by which many of them are often held together in a mass or group, tech- 
nically called zooglcea. Each bacterium represents a cell, although the pres- 
ence of a nucleus, or something representing such a structure, has not been 
demonstrated; but its cellular structure is made evident by its intrinsic 
power, of germination or reproduction when surrounded by the necessary 
conditions for its growth. Some of the bacteria are provided with processes, 
or cilia, by which, when suspended in a fluid, movements are accomplished; 
in others motion is entirely dependent on molecular movements described 
by Brown. Nageli, and formerly Billroth, claimed that all bacteria had a 
common botanical source, and that the different forms and actions only rep- 
resented alteration of form of action of the same plant at different stages of 
development and under different circumstances, — in other words, that a 
coccus could be transformed, into a bacillus, and vice versa; and that in one 
instance the same plant caused fermentation, in another putrefaction, and 
that all infective diseases were caused by the same microbe. Buchner main- 
tained that, by cultivation in different nutrient media,. he was able to trans- 
form the dangerous bacillus of anthrax into the harmless bacillus subtilis, 
and, again, the latter into the former. Cultivation and inoculation experi- 

(157) 



158 



PEINCIPLES OF SURGERY 



ments on a large scale by most careful observers have shown conclusively 
that such transformations never take place, and that each microbe not only 



Kv.* .:.v 

• • • • 



•!«<«. 



yfiJV 









/ 



- \ 



-^ 



i-v/ 1 



^ &' 





Fig. 77. — Different Forms of Bacteria. A, cocci; B, bacilli; V, spirilli. (Baumgarten.) 

always retains its shape, but also its specific pathogenic properties. Pus- 
and other microbes have been cultivated through thirty and more genera- 
tions without suffering any morphological deviations or losing any of their 



MULTIPLICATION OF BACTERIA. 159 

inherent characteristic pathogenic properties. The three principal morpho- 
logical forms of bacteria discovered up to the present time, and which have 
been demonstrated as causes of disease, are: (1) the ball (coccus); (2) rod 
(bacillus); (3) corkscrew (spirillum). As illustrations for these different 
forms, de Bary very appropriately takes the billiard-ball, lead-pencil, and 
corkscrew. 

The surgeon has to deal only with the first two forms: the cocci and 
bacilli. Modifications of form are frequently met with, as an oblong coccus 
closely resembles a short bacillus, and a short, broad bacillus with rounded 
ends approaches the coccus form. Again, a double coccus, or diplococcus, 
with ill-defined constriction at the point of junction, might, from superficial 
examination, be mistaken for a bacillus (Fig. 77, A, 2). More than two 
cocci in a row, or a chain of cocci, are called a streptococcus (A, 3). Four 
cocci arranged in the form of a square are called a micrococcus tetragones 
(A, 4). Cocci arranged in the form of a bunch of grapes are called staphylo- 







Fig. 78.— Zooglcea. 



cocci (A, 6). An irregular mass of cocci, when at rest and held together by a 



viscid substance, is described as a zooglcea. 



MULTIPLICATION" OF BACTERIA. 

Bacteria multiply with great rapidity in tissues presenting favorable 
conditions for their growth, or in proper nutrient media kept at a temper- 
ature approaching that of the body. Multiplication takes place either by 
fissure or segmentation, by the production of spores, or both of these meth- 
ods. The bacillus of anthrax multiplies by fission in the body, by spores 
outside of the body. 

Fission. — The round or globular bacteria, — the cocci, — as far as we 
know, multiply only by fls'sion. The cell elongates prior to segmentation, 
when a constriction appears in the centre, which, by becoming deeper and 
deeper, finally results in complete division of the cell into two equal halves, 
which soon attain the size of the mother-cell, and, in turn, again undergo 
the same process. If the new cells remain adherent and arrange themselves 
in the form of a chain, a streptococcus is formed. Fliigge observed complete 
division of a coccus in bouillon, kept at a temperature of 35° C, in twenty 



160 PRINCIPLES OF SURGERY. 

minutes. If it should require one hour to complete segmentation and for 
the new cell to attain maturity, a single coccus multiplying by fission, ac- 
cording to Colin, during one day, would produce sixteen millions of cocci, 
and at the end of the second day the product would represent two hundred 
and eighty-one billions in number, and at the end of three days the extraor- 
dinary number of forty-seven trillions would be reached. Eod bacteria 
which reproduce themselves by fission undergo transverse segmentation in 
the middle, and after complete separation each segment grows to the size of 
the parent-cell before the process repeats itself. 

Spores. — The spores of bacteria represent the seed of flowering plants. 
Each spore develops into a bacterium, and thus one crop after another is 
produced, the multiplication increasing with the number of bacteria in the 




Fig. 79.— Endogenous Spore-production in Bacillus Anthracis Cultivated upon Meat- 
Infusion Peptone-Gelatin. X 950. {Baumgarten.) 

soil. Most of the bacilli multiply by spores. Fructification again takes 
plar^e, either within the protoplasm of the cell (endospore) or at one or both 
extremities of the cell (endspore). Fructification is often preceded by a rapid 
elongation of the bacillus. Multiple endospores usually form in one bacillus 
simultaneously. The first evidences of the formation of spores within the 
protoplasm of a bacillus is indicated by the appearance of circumscribed 
points of cloudiness at equidistant points. 

After the expiration of twenty hours the bacillus appears like a string 
of pearls, each segment of which represents a fully-developed spore. After 
this the segments separate and each spore develops into a bacillus. If the 
bacillus reproduce itself by a single endospore, it does not elongate before 
fructification, but increases in diameter, especially in the centre, so that it 



MULTIPLICATION OF BACTERIA. 161 

assumes the shape of a spindle: while, equidistant from its ends, changes are 

observed in the protoplasm which indicate the beginning of spore-formation. 
If the bacillus multiply by terminal fructification, one or both of its ends 
enlarge, become club-shaped, and the spores pass through the same sta_ 
development as the endospores, and they are liberated in the same manner, 
by liquefaction of the cell-membrane surrounding them. Bacteriologists are 
familiar with the fact that spores possess a greater power of resistance to 
germicidal agents than the bacilli which produced them. Mature bacteria 
are always destroyed by a temperature of 77° C; most of them succumb 
when exposed to a heat of 50° to 55° C. On the other hand, some of the 
spores are known to survive a temperature of 100° to 120° C. 

Macfayden and Bloxall have made a careful examination into the tem- 
perature most congenial to the growth of bacteria, and have found that some 
of them germinate most vigorously at a high temperature, and they apply 
to such the designation thermophilic bacteria. Experiments were made with 
temperatures ranging from 60° to 65° C. Such, bacteria were found in the 
faeces of man and the lower animals, in Thames water and mud, street-dust, 
straw and sea-water. All the organisms isolated were bacilli, some twenty 

ill 

,2 3 
Fig. 80. — Spore of Bacillus of Anthrax. X 6-700. S, ripe spore before germination; 1, 2, 3, 
three successive stages of germinating spore; 3, young rod. (De Bary.) 

different forms were isolated. The first culture was obtained at a tempera- 
ture from ±0° to 4:2° C. The most favorable temperature was from 60° to 
65° C. A temperature of 75° C. proved destructive to all of them. The 
wide distribution and active fermentative properties of thermophilic bacteria 
point to their fulfilling some important function in the economy of nature. 
Sternberg has determined the thermal death-point of the following- 
pathogenic bacteria : — 

Fahr. 

Bacillus anthracis (Chaveau) 129.2° 

Baeillus-anthracis spores 212.0° 

Bacillus tuberculosis (Sehill and Hischer) 212.0° 

Staphylococcus albus 143.6° 

Staphylococcus pyogenes aureus 136.4° 

Staphylococcus pyogenes citreus 143.6° 

Streptococcus erysipelatosus 129.2° 

Gonococcus 140.0° 

In all experiments, with the exception of the bacillus of tuberculosis, 
the microbe was subjected to the specified heat for ten minutes: the tubercle 
bacillus was destroyed in four minutes. Such resisting spores are often not 



162 PRINCIPLES OF SURGERY. 

destroyed by boiling continued for several minutes, and yield only slowly 
and frequently imperfectly to germicidal chemical agents. Surgeons are 
aware that such spores may remain dormant in the body for years without 
giving rise to any symptoms until aroused to activity by surrounding con- 
ditions favorable to their growth and development. 

CULTIVATION OF BACTERIA. 

The first cultivation experiments were made with fluid nutrient sub- 
stances, such as 'bouillon, different animal broths, and solutions of sugar. 
Koch introduced solid nutrient media, which not only serve as food for the 
bacteria, but at the same time present the great advantage that the colonies 
can be seen with the naked eye, and their macroscopical appearances, as well 
as the visible action of the bacteria on the nutrient substance, often are suffi- 
cient to convey reliable information to enable the observer to form a posi- 
tive conclusion in reference to the kind of microbes of which the colonies 
are composed. In fluid nutrient media the bacteria cause turbidity, or they 
appear as a thin film on the surface; or zooglcea masses show themselves as 
swimming flocculi; or, finally, when the fluid has been exhausted of its 
nutrient supply the spores settle at the bottom of the vessel and appear as a 
pulverulent deposit. Upon solid nutrient media each kind of bacteria ap- 
pears as an isolated, distinct colony, and as such can be recognized by the 
naked-eye appearances. 

The substance used first by Koch as a solid medium, and which is now 
used more than any other, was gelatin. Later, a jelry-like substance called 
agar-agar, obtained from several sea-weeds on the coasts of Japan and India, 
was found superior to gelatin where a higher than ordinary temperature was 
required to cultivate certain microbes. Edington prefers a gelatin made of 
Irish moss to agar-agar, as it is more transparent. Some microbes that will 
not grow upon gelatin vegetate luxuriantly on solid blood-serum. The tu- 
bercle bacillus grows equally well upon solid blood-serum and glycerin agar- 
agar. This latter substance is easily prepared, and is made by adding 6 per 
cent, of pure glycerin to the ordinary agar medium. 

The busy practitioner, who has no time to prepare the media used in 
laboratory work, can do good bacteriological work by using sterilized potato 
or bread-paste. The potato is the best medium for the cultivation of chro- 
mogenous bacteria, as upon this substance the color is preserved. The 
potato is scrubbed with a hard brush under a stream of water. It is then 
left in a solution of corrosive sublimate (1 to 1000) for an hour or so to 
disinfect its surface. With a knife rendered sterile by passing it through the 
flame of a Bunsen lamp, a quadrilateral piece is cut from the centre, and is 
rapidly transferred on the knife to a glass capsule previously sterilized by 
heat. Capsule and potato are next placed in a steam sterilizer, when the 



CULTIVATION OF BACTERIA, 



L63 



simple apparatus is ready for inoculation. Inoculation is done by charging 
the point of an aseptic needle with the culture or substance containing the 
microbes, and, after Lifting the capsule half up, a number of streaks are made 
with the needle upon the surface of the potato. A potato-paste, made by 
adding a sufficient quantity of distilled water to the interior portion of boiled 
potatoes to make a paste, is used in the same manner and answers the same 
purpose as sterilized raw potato. 

Bread-paste is made of stale, coarse bread, thoroughly dried in an oven, 
but not roasted. It is pulverized in a clean mortar and the powder made into 
a paste by adding distilled water. The paste is transferred to sterile glass 
capsules and used in the same manner as potato-paste. If it is employed 
for the culture of bacteria, it must be neutralized with a solution of carbonate 







Fig. 81. — Gelatin Cultures following Surface Inoculation. (Fliigge.) 

of soda. Some microbes possess the faculty of liquefying the gelatin; others 
remain as solid cultures upon the surface of the medium, or its interior. 
Free access of oxygen to the seat of inoculation is essential for the growth 
of some microbes, and these were termed by Pasteur aerobic, while those that 
germinate with exclusion of oxygen he called anaerobic. The former class 
germinate on the surface of the media with or without liquefaction of the 
soil. If microbes of this kind are inoculated by scratching the surface of 
the medium with the point of a needle charged with them, the culture ap- 
pears first at isolated points (Fig. 81, A), which by increase in size become 
confluent and occupy as a solid mass the whole track made by the needle 
(B, C). A microbe which requires oxygen and grows only in the presence 
of this gas is said to be aerobic. A facultative anaerobic microorganism grows 



164 



PRINCIPLES OF SURGERY. 



and develops either in the presence of oxygen or in its absence. An anaerobic 
microbe cannot grow in the presence of oxygen and, consequently, grows only 
below the surface of solid nutrient media. Microbes which usually lead a 
saprophytic existence, but which can also thrive within the living body, are 
called facultative parasites. The bacillus of lepra is a strict parasite, while 
the typhoid bacillus, the cholera spirillum, etc., are facultative parasites, 
inasmuch as they are capable of living and multiplying, under favorable con- 
ditions, external to the bodies of living animals. 

In making inoculations with anaerobic bacteria the gelatin is punctured 
with a needle, charged as before, to some depth, and isolated colonies appear 
in the track made by the needle, which by confluence form a continuous un- 
interrupted culture the whole depth of the needle, which increases in diam- 






Fig. 



-Cultures in Gelatin growing in the Track made by the Needle. (Fliigge.) 



eter by extension in a peripheral direction. Superficial cultures are called 
streak cultures; deep cultures, stab cultures. 

All cultivation experiments must, of course, be conducted under strictest 
aseptic precautions, as otherwise there is great danger of contamination 
of the cultures by the accidental ingress of other microbes, especially of some 
forms of fungi. 



ESSENTIAL CONDITION FOR GROWTH OF BACTERIA. 

For the germination of bacteria, besides a proper nutrient substance 
the other conditions which enable the growth of other plants from seed are 
necessary, viz.: moisture and a certain degree of heat. Inspissation of a 
solid nutrient medium arrests further development of a culture. Bacteria 



Ai Tlu\ OF BACTERIA OX TISSUES OF THE BODY. 165 

cannot grow upon a perfectly dry medium. Most microbes germinate best 
at a temperature corresponding to blood-heat, but in this respect the differ- 
ent kinds show great variance, as some vegetate at 10° C, while the growth 
of others will continue at 6o° C. Acids appear to produce an inhibitory 
effect on the process of germination. Laplace has utilized this fact and ad- 
vises the addition of citric acid to solutions of corrosive sublimate to in- 
tensify its germicidal properties. It is well known that the gastric juice 
suspends the growth of most bacteria. Bacteria which live on dead sub- 
stances exclusively are called saprophytes. Bacteria which feed on dead sub- 
stances and can exist in the living tissues only at a certain stage of develop- 
ment are called facultative parasites, in comparison with the obligatory para- 
sites, which multiply exclusively in the living tissues. As representatives of 
the former can be enumerated the bacillus of anthrax and cholera, which, 
under favorable conditions, can multiply outside of the body, while the bacil- 
lus of tuberculosis germinates only in the living body. 

It has recently been ascertained that some bacteria exert a decided effect 
on toxic alkaloids. Thus, S. Holenghi found that the potency of weak atro- 
pine solutions in bouillon was progressively weakened by cultures of the 
bacillus coli commune and other putrefactive bacteria. Solutions of strych- 
nine showed at first an increase to double or treble the original toxicity, 
which was estimated by observing the degree of dilution in which a distinct 
physiological effect was still obtainable, followed by a gradual diminution 
after the end of the first week. 

ACTIOX OF BACTERIA OX TISSUES OF THE BODY. 

The action of pathogenic bacteria on the tissues is a twofold one. In 
the first place, they abstract from the body a part of its essential constituents; 
for example, albuminous substances, carbohydrates, oxygen, etc. These sub- 
stances are not only taken from the fluids of the body, as the blood and 
lymph, but also directly from the protoplasm of the cells. In the second 
place, they produce in the body toxic agents from their action on the albu- 
minoid substances. The decomposition of albuminoid substances by the 
action of bacteria results in the formation of ammonia and its derivatives, 
the different amines, C0 2 , H 2 S, indol, scatol, phenol, asparagin, leucin, 
tyrosin, etc. 

Toxins and Ptomaines. — The common names for the toxic substances of 
bacterial origin are ptomaines and toxins. Brieger has isolated a number 
of ptomaines from cultures of different bacteria, and Hoffa followed him in 
the same kind of work. Vaughn, of this country, has written a valuable 
work on this subject, which should be read by all who wish to become familiar 
with modern surgical pathology. Brieger has isolated a number of toxic 
alkaloids — cadaverin, neurin, muscarin, and mydalein — which are intensely 



166 PKINCIPLES OF SUEGEKY. 

toxic, while the derivatives of ammonia — dimethylamin, trimethylamin, and 
triathylamin — are much less dangerous substances. The ptomaines being 
soluble substances, are readily absorbed, and when introduced into the cir- 
culation produce fever and symptoms of sepsis. The toxins of the bacillus 
of tetanus act principally upon the central nervous system, producing char- 
acteristic tonic and clonic spasms of definite groups of muscles. The 
toxins also produce a definite local effect, — thus, the toxins of pus-microbes 
transform the leucocytes and embryonal cells into pus-corpuscles, those 
of the microbe of progressive gangrene destroy the protoplasm of the cell- 
body directly, while the toxic substances of the microbes of chronic infect- 
ive diseases transform the fixed tissue-cells into embryonal or granulation 
cells. Some of the microbes remain in the tissue at the seat of infection; 
others localize in the lymphatic channels; while, finally, others enter the 
general circulation and multiply in distant organs. The production of pto- 
maines and toxins usually takes place in the tissues in which localization 
takes place. 

ANTITOXINS. 

Much has been done during the last decade by bacteriologists to discover 
a bacteriological product that would antagonize the pathogenic action of dis- 
ease-producing microbes. These bacterial therapeutic agents are called anti- 
toxins. This field is an immense one, and its faithful cultivation is full of 
promise. Much has been accomplished; much more awaits the patient in- 
vestigators. The greatest triumph so far has been achieved b_y Behring. 
His discovery has robbed diphtheria of its many terrors. Thousands of chil- 
dren owe their lives to the diphtheria antitoxin. 

The antitoxins which have been found efficient unite with the toxins 
and form harmless chemical compounds, as opposed to the theory that 
antitoxins are curative by their stimulating action on the tissues; in other 
words, by exciting an active process of phagocytosis. 

The reactions obtained outside of the body indicate a direct chemical 
action between toxins and antitoxins, ferments and antiferments, of various 
kinds. Toxins are akin to enzymes by their great activity in small quanti- 
ties and by their instability in the presence of chemical and plrysical agents; 
but the exact nature and mode of action of both are as yet but imperfectly 
understood. 

Behring, in discussing the quantitative relations of the combination 
between tetanus toxin and tetanus antitoxin in the body of a living guinea- 
pig, concludes that the chemical union of the two substances and the neu- 
tralization of the toxin occurs wherever in the body the two substances come 
together. In the interval before chemical union of the poison and the anti- 
toxin occurs, some of the poison in the blood may pass out of the vessel and 






ATTENUATION OF PATHOGENIC BACTERIA. l'^ 

thus escape union with antitoxin in the blood. In order to reach the extra- 
vascular toxin the antitoxin must also pass through the vessel-walls. This 
does occur, and in greater degree the more concentrated the antitoxin in 
the blood. Antitoxin immunity is high and the therapeutic action prompt 
in proportion to the amount of antitoxin held by each cubic centimetre of 
blood. 

INOCULATION EXPERIMENTS. 

The mouse, rat, rabbit, guinea-pig, and dog are the animals usually 
selected for this purpose. Inoculations are made either with pure cultures, 
which are injected by means of a sterilized hypodermic syringe, or infected 
tissues are implanted under strict aseptic precautions. Injections of pure 
cultures are made either into the subcutaneous tissue or one of the large 
serous cavities: the pleural or peritoneal cavity. The same localities are 
generally selected for inoculation by means of implantation of infected tis- 
sue. For instance, granulation-tissue from tubercular lesions either is intro- 
duced into a small pocket made in the subcutaneous tissue in the inguinal 
region of a guinea-pig or a small fragment is inserted into the pleural or 
peritoneal cavity through a small incision. Before the incision is made it 
is absolutely necessary to shave the surface and disinfect it in the usual way. 
After the implantation is made the wound is closed by suturing with fine 
catgut, after which it is sealed with collodium. In the course of two or three 
weeks the subcutaneous graft has become the centre of a local tubercular 
focus, which soon gives rise to regional infection through the lymphatic ves- 
sels, to be followed at the end of five or six weeks by general diffuse miliary 
tuberculosis. In cases where it is impossible to make a differential diagnosis 
between a syphilitic and tubercular lesion, inoculation of a guinea-pig with 
a fragment of the granulation-tissue will furnish positive information in 
the course of a few weeks. If the lesion is syphilitic, the result of the in- 
oculation will be negative; if it is tubercular, local, regional, and general 
infection will follow in regular order. In making implantation experiments 
from animal to animal, it is necessary to remove the graft immediately, or 
soon after death, and to resort to the necessary precautions to prevent con- 
tamination during its conveyance from the dead to the living animal. In 
bacterial diseases which affect the blood, inoculation can be practiced by 
injecting blood, abstracted from the infected animal, into the subcutaneous 
tissue or general circulation of a healthy animal, with the effect of repro- 
ducing the disease. Anthrax and septicaemia of mice furnish good illustra- 
tions of this class of infective diseases. 

ATTEXUATIOX OF PATHOGEXIC BACTERIA. 

Pasteur opened a wide field for investigation in preventive medicine 
by his introduction of prophylactic inoculations. He experimented first 



168 PRINCIPLES OF SURGERY. 

with the microbe of chicken-cholera and the bacillus of anthrax. The mi- 
crobe of fowl-cholera was cultivated in chicken bouillon for three, four, five, 
or eight months. He found that by that time the virus became so attenuated 
that, when injected into a healthy chicken, it killed only in exceptional cases. 
Experience showed that attenuation only occurred when the culture was 
freely exposed to atmospheric air, and therefore Pasteur believed that the 
prolonged contact of the culture with oxygen diminished its virulence. 
Chickens inoculated with weak cultures were rendered immune to the action 
of the active virus. The same author made the discovery that the anthrax 
bacillus, cultivated in the same way at a temperature ranging between 40° 
and 43° C, loses its virulence gradually, so that on the ninth day it is ren- 
dered harmless. Inoculation with attenuated cultures protected sheep 
against the active virus. Koch, G-affky, and Loftier found that a culture of 
anthrax bacilli twenty days old, attenuated at a temperature of 42° to 46° 
C, was still sufficiently strong to kill mice, but had little effect on guinea- 
pigs and sheep. A culture twelve days old killed guinea-pigs, but not sheep. 
It proves fatal to sheep up to six days of cultivation. Their views in refer- 
ence to the cause of attenuation differ from Pasteur's, who regards oxygen 
as the active agent, while these observers attribute it exclusively to the high 
temperature. They, like Pasteur, by using attenuated cultures, succeeded 
in protecting, in most cases, sheep against the action of virulent cultures. 
In his practical work Pasteur uses two strengths of mitigated virus. The 
milder vaccine is a culture fifteen to twenty days old; the stronger vaccine 
is from ten to twelve days old. Sheep are inoculated first with the milder 
vaccine, and after an interval of twelve to fifteen days the stronger culture 
is used. Animals thus treated are either entirely immune to anthrax or, if 
they contract the disease, it assumes a mild type. Other methods of attenua- 
tion of active cultures to be used for prophylactic inoculations have been 
devised, but, as they appear to have been put only to a limited extent to 
practical tests, they will be only briefly mentioned here. Sanderson found 
that the bacillus of anthrax loses much of its virulence when passed through 
the system of a guinea-pig. Toussaint and Chaveau found that the action 
of a temperature of from 50° to 55° C, continued for five to twenty minutes, 
greatly diminishes the virulence of the bacillus of anthrax. For the attenua- 
tion of spores a temperature of 80° C. is required. 

Paul Bert showed that oxygen, under a pressure of from 20 to 40 centi- 
metres, destroys the bacillus of anthrax. Toussaint, Chamberland and Koux, 
and Klein made experiments to determine the influence of chemical agents 
in effecting attenuation of active cultures, and their work has shown that 
the virulence of some bacteria can be greatly diminished and even entirely 
suspended by this method of treatment. Arloing asserts that anthrax bacilli, 
exposed to a bright sunlight in a liquid medium, gradually part with their 



THEBAPEUTIC INOCULATION. 169 

toxic qualities. More accurate knowledge and greater experience in this 
interesting field of prophylactic inoculations will undoubtedly lead to 
important results in the near future. 

THERAPEUTIC INOCULATION. 

Therapeutic inoculations have been put to a practical test upon a knowl- 
edge obtained from laboratory work, that direct antagonism exists among 
certain kinds of microorganisms. Emmerich's experiments on rabbits have 
demonstrated the value of the streptococcus of erysipelas as a protective and 
curative agent in anthrax in these animals. In one series of experiments 
the rabbits were first inoculated with a large quantity of a reliable culture 
of the microbe of erysipelas, and then, two to fourteen days later, the ani- 
mals were infected with a pure culture of the anthrax bacillus. Of 15 ani- 
mals treated in this way, 7 recovered, while all the control animals inoculated 
only with anthrax died; of the 7 animals which died after double infection, 
some succumbed to the anthrax bacillus and some to the streptococcus of 
erysipelas. Therapeutic inoculations with cultures of the microbe of ery- 
sipelas in animals suffering from anthrax were less successful. G-arre has 
studied antagonism among bacteria on culture-soils. He made many careful 
experiments to determine the growth of a culture on different nutrient 
media, by removal of the entire culture with a minute spade and inoculation 
of the same soil with another microbe. From the results obtained thus far 
he has ascertained that some microbes affect the soil favorably for the growth 
of other varieties, while others render it sterile. For example, a culture- 
medium impregnated with the ptomaines of the bacillus fluorescens putidus 
remains perfectly sterile when inoculated with pus-microbes. These in- 
vestigations have an important practical bearing, as future research may not 
only show the way to secure immunity from infection by pathogenic microbes 
by proplrylactic inoculations with harmless microbes, but may likewise es- 
tablish a system of rational and effective treatment by inoculations of cult- 
ures of antagonistic bacteria for therapeutic purposes. Therapeutic inocula- 
tions with potent cultures have also been made with some success in the 
treatment of inoperable malignant tumors. In a recent publication on this 
subject Bruns gives the result of 22 cases of malignant growths, including 
1 that came under his own observation that passed through an attack of 
erysipelas. Bruns' case was one of melanosarcoma of the breast, in which 
a final cure followed the attack. Out of 5 sarcomata, 3 were permanently 
cured, while the other 2 were diminished in size, but soon returned to their 
former size. The effect of the erysipelatous invasion proved negative in 6 
cases, in which the diagnosis between carcinoma and sarcoma could not be 
positively made, as also in 3 cases of ulcerating epithelioma. It is stated 



170 PRINCIPLES OF SURGERY. 

that in cicatricial keloid and lymphomata the attack of erysipelas proved 
curative. 

IMMUNITY. 

The antiseptic properties of blood-serum are now generally recognized. 
These properties are due to the existence of a substance known as globulin,- 
and upon the presence of this substance depends the natural immunity of 
certain animals and persons to some diseases and the immunity artificially 
produced by the employment of serum obtained from immune animals or 
injections of chemically-prepared antitoxins. Hankin thus defines im- 
munity: "Immunity, whether natural or acquired, is due to the presence of 
substances which are formed by the metabolism of the animal rather than 
that of the microbe, and which have the power of destroying the microbes 
against which immunity is possible or the products on which their pathog- 
enic action depends." The clinical observations relating to the immunity 
acquired after an attack of certain acute infectious diseases and the experi- 
mental evidences which have accumulated on the same subject tend to sup- 
port the theory that acquired immunity depends upon the formation of 
antitoxins in the bodies of immune persons and animals and that it can also 
be produced hj introducing into the system preformed antitoxins. As sec- 
ondary factors, it is probable that tolerance to the toxic products of pathog- 
enic microbes and phagocytosis are also active, but to a lesser extent. 

BACTERIA OUTSIDE OF THE BODY. 

Bacteriology has rendered the term miasma obsolete. All infective dis- 
eases are now traced to an organic contagium. Most of the bacteria are 
ectogenous; that is, they exist and, under favorable circumstances, multiply 
outside of the body. The microbe of syphilis, in all probabilit}^, is an endog- 
enous parasite. Autoinfection is a misapplied term, as nearly all, if not all, 
infective diseases are caused by the introduction into the body of pathogenic 
bacteria from without. Some microbes exist' in the soil, and as they or their 
spores may exist in an active condition for an indefinite period of time, or 
even germinate there, they give rise to endemics and epidemics of infective 
diseases. The anthrax bacillus, the bacillus of tetanus, and the actinomyces 
can be included in this category. Other microbes are diffused over large 
territories through water-courses, as the bacillus of typhoid fever and 
cholera, and become the cause of epidemics of these diseases. Finally, some 
bacteria, like pus-microbes, appear to be ubiquitous, being present every- 
where and at all times. Of all substances which serve as a carrier of mi- 
crobes, the atmospheric air is the most important, because it is present 
everywhere on the surface of the globe, and no one can exclude himself 
from it. In a dry state, pathogenic bacteria move with the currents of air 



PBESENCE OF PATHOGENIC BACTERID IX THE II KA l/l'll Y BODY. Ill 

and attach themselves again to the solid or fluid substances with which they 
come in contact. Although most of the pathogenic bacteria under ordinary 
circumstances do not reproduce themselves outside the body, their resistance 
to heat and cold, moisture and dryness, is so great that they retain their 
disease-producing qualities often for an indefinite period of time, and after 
their entrance into the body, and meeting with a proper nutrient medium, 
they exert their specific pathogenic effects. From a practical stand- point 
it is important to remember that infection takes place by the entrance into the 
tissues or body of microorganisms from without, through some defect of the 
skin or mucous membranes; hence by contact entrance of bacteria into the 
body is effected. As a rule, to which there are few exceptions, bacteria are 
introduced into the body through a wound, abrasion, or ulceration of the 
skin or a mucous membrane. Such a defect or gateway is called an infection- 
atrium. A healthy, granulating surface furnishes almost as secure a pro- 
tection against infection as the skin, but, when the granulations are destroyed 
or injured, infection is again liable to occur. On this account probing of a 
fistulous canal has not infrequently resulted in aggravation of the local 
symptoms, and even in general infection. Krister reports two cases where 
patients who had undergone an operation for hydrocele by incision, and 
who were permitted to leave the hospital before the wound had completely 
healed, died subsequently from sepsis caused by careless after-treatment of 
the granulating surface. Most of the microbes, after they have become 
deposited upon an absorbing surface, exercise first their pathogenic qualities 
at the seat of primary localization. The action of some of them always re- 
mains local. If the infection spread, it does so by dissemination of the mi- 
crobes over a surface, along the connective tissue, or through the lymphatics 
or blood-vessels. There is no reason to doubt that bacteria can gain entrance 
into the tissues and the circulation by passing through intact mucous mem- 
branes in the same manner as minute particles of inorganic material, like. 
coal-, marble-, and ivory- dust. This brings up the question of the 

PRESENCE OF PATHOGEXIC BACTERIA IX THE HEALTHY BODY. 

It still remains a disputed question whether pathogenic microorganisms 
can exist in the body without giving rise to disease. It has been definitely 
ascertained, by experimental research, that many of the pathogenic microbes 
are harmless so long as they remain in the circulating blood, and that their 
specific pathogenic action only becomes evident after localization has taken 
place in some part of the body, in a soil prepared by injury or disease for 
their reproduction. It has also been conclusively shown, by clinical experi- 
ence, that pathogenic spores may remain in the healthy body, in a dormant 
condition, for an indefinite period of time, until, by some accidental patho- 
logical changes, the tissues in which they may exist have been prepared for 



172 PEINCIPLES OF SUEGEEY. 

their germination. Numerous experiments will be cited elsewhere, in which 
injections of pure cultures directly into the circulation produced no ill 
effects in healthy animals, but when, previous to the injection or soon after, 
an injury was inflicted in some part of the body, localization occurred at the 
seat of trauma, and in the locus minoris resistentiw thus created the microbes 
produced their specific pathogenic effects. From these remarks it is reason- 
able to assume that pathogenic microbes may and do exist in the healthy body 
without necessarily giving rise to disease, especially if, as is well 'known, they 
are being constantly eliminated through the excretory organs. 

Bizzozero could not detect bacteria of any kind in animals soon after 
birth, but in the lymph-follicles of the caecum in healthy rabbits he found 
numerous microorganisms. They were seen mostly in the protoplasm of 
cells: a condition which would indicate that they are transferred from the 
intestinal canal into the closed lymph-follicle through the medium of mi- 
grating cells. In the human subject Eibbert found microorganisms in the 
interior of the epithelia lining the intestinal canal, but they were absent in 
the submucosa. Perhaps the epithelial cells in this locality take the part of 
phagocytes. Kalbe found that in the larger majority of cases the peribron- 
chial glands of hogs contain bacteria such as the pus-microbes, the bacillus 
capsulatus, and micrococcus lanceolatus, demonstrable by cultural methods. 
In two of twenty-three non-tubercular human bodies, dying from acute in- 
fectious diseases or accidents he found tubercle bacilli in these glands. 
While it seems reasonable to assume that the peribronchial glands exercise 
some antibacterial influence upon the bacteria they frequently retain, it 
should also be noted that these glands might become the infection-atrium 
of organisms giving rise to cryptogenetic infections. The common sapro- 
phyte proteus vulgaris was found to be pathogenic for rabbits when injected 
into the dorsal muscles in sufficient numbers. But, according to the esti- 
mates made, 225,000,000 were required to cause death, while, with doses of 
from 9,000,000 to 112,000,000, a local abscess was produced, and less than 
9,000,000 gave an entirely negative result. Watson-Cheyne found, in his 
experiments made for the purpose of ascertaining the presence of microor- 
ganisms in the living tissues, that, while they were not present when the 
animal was in good condition, yet, if the vitality of the animal was de- 
pressed, say, by administering large doses of phosphorus for some time, mi- 
crobes could be found, at times, in the blood and tissues of the body. Again, 
it has been found that, while some microorganisms, when introduced into 
the living body in small number, disappear after a short time, when a large 
quantity of the culture is introduced the tissues of the body are injured by 
the preexisting toxins, and the microbes retain their vitality and often 
cause inflammation of the organ in which they locate. The conditions, then, 
upon which depend the preservation of health, in the event of the entrance 



LOCALIZATION OF BACTERIA. 173 

of pathogenic microbes into the body, are: 1. The number of microbes in- 
troduced. 2. Absence of a locus minoris resist&niice. 3. Active elimination 
through the excretory organs. 

LOCALIZATION OF BACTERIA. 

Every surgeon has had frequent opportunities to observe cases in which 
a slight subcutaneous injury was followed by a destructive inflammation: an 
inflammation not caused by the trauma alone, but by the trauma giving rise 
to localization of pathogenic microbes in the tissues altered by the injury. 
Thus, Chaveau has shown experimentally that a subcutaneous contusion fur- 
nishes an excellent condition for the localization of pathogenic bacteria car- 
ried to the part by the circulating blood. When he injected a putrid fluid 
directly into the circulation of young rams shortly before crushing subcu- 
taneously one of the testicles, the injured organ always became the seat of 
septic gangrene, while without such injection the testicle disappeared com- 
pletely by necrobiosis and absorption. Gangrene only occurred if the putrid 
fluid contained bacteria; it did not take place when the injected fluid had 
been sterilized by filtration. Extensive subcutaneous injuries — as severe 
contusions, rupture of tendons or muscles, and comminuted fractures — are 
not followed by suppuration unless the injured tissues become subsequently 
the seat of infection with pus-microbes. A patient may have been the sub- 
ject of tubercular infection for an indefinite period of time, and yet may 
present the appearances of ordinary health, until some slight injury deter- 
mines localization of the bacillus in the part injured: an occurrence which 
is followed by a localized tuberculosis from which, later, regional and gen- 
eral dissemination takes place, to which the patient finally succumbs, unless 
the tubercular focus is removed by an early operation. These facts suggest 
very strongly that, in the hypothetical cases, suppuration and tuberculosis 
would not have occurred in the part injured without the injury, and that the 
injury certainly would not have produced suppuration or tuberculosis unless 
the respective patients have been infected previously with the specific microor- 
ganisms. The injury in these cases created a so-called locus minoris resisten- 
tice, which may signify one of two things: (1) diminution or suspension of 
the vital resistance on the part of the injured tissues to the action of pathog- 
enic microbes; or (2) the injury so alters the tissues that bacteria, which were 
present in the circulation without having given rise to s}anptoms, become 
arrested and find at the same time, at the seat of localization, the necessary 
conditions for their reproduction. Huber studied experimentally the effect 
of chemical irritation of tissues in determining localization of the bacillus 
of anthrax. The experiments were made on rabbits, in which, by the ex- 
ternal application of croton-oil to the ear, he produced a tissue-lesion by the 
inflammation which followed. One ear was thus treated, the other beiiw 



174 PRINCIPLES OF SURGERY. 

left in a normal condition in order to compare the results of localization of 
anthrax bacilli in inflamed and normal vessels. As soon as the inflammation 
was established, a pure culture of anthrax bacilli was inserted subcutaneously 
at the root of the tail; this place was selected in order to make the infection 
as distant as possible from the inflamed ear. In some cases the croton-oil 
was applied after the inoculation. Immediately after the death of the ani- 
mal, both ears were cut off and carefully preserved for subsequent examina- 
tion, and, at the same time, serum and blood were separately taken from the 
inflamed ear and preserved in sterilized glass tubes. 

The results of a number of these experiments enabled the author to 
assert that in all stages of the inflammation the bacilli were never found out- 
side the walls of the capillary blood-vessels in the crotonized ear. Their 
number within the blood-vessels depended upon the condition of the in- 
flamed vessels. During the first stage of inflammation, marked by oedema 
without suppuration, more bacilli were found within the inflamed vessels 
than in the corresponding vessels of the opposite ear. During the suppura- 
tive stage the bacilli disappeared from the vessels. During the third stage, 
when granulations commenced to form, a complete change was again ob- 
served in the bacteriological condition of the inflamed part. The height of 
this stage is reached on the tenth day. During this stage the bacilli reap- 
peared in the inflamed tissue, where they could be seen in considerable num- 
ber, especially in the interior of new capillary vessels. During cicatrization 
the number of bacilli in a corresponding area of both ears was about the 
same. 

From these observations the author concludes that the bacillus of 
anthrax finds, in a soil prepared by inflammation induced with croton-oil, 
a locus minoris 7-esistentice which presents more favorable conditions for its 
localization and growth than the tissues in other parts of the body. Sup- 
puration appeared to neutralize the anthracic process by the destructive 
effect of the pus-toxins upon the bacilli. 

The conclusions which he has drawn from his experiments may be sum- 
marized as follows: Localization of preexisting microorganisms in tissues 
prepared by injury or disease takes place, provided that the necessary condi- 
tions for their growth are present. In looking over different pathological 
conditions we frequently meet with a so-called locus minoris resistentice; at 
any rate, if we search only for that which should mean what has been de- 
scribed above, it is not difficult to conceive how slight injuries, wounds, 
contusions, etc., should in this manner give rise to serious affections. But 
not only do direct tissue-lesions, as haemorrhage, necrosis, hyperaemia, fract- 
ures, etc., act in this manner, but a variety of pathological conditions of a 
general nature may serve the same purpose, as imperfect digestion, enfeebled 
circulation and respiration, and particularly irregular distribution of blood 



LOCALIZATION OF BACTERIA. 175 

resulting from exposure to cold. All these ill-defined conditions belong here, 
and through their instrumentalities the localization of infective microbes 
is favored. In secondary or mixed infection the microbes which exist in the 
tissues first prepare the soil for the arrest and germination of other bacteria 
which may reach the circulation. 

Muskatbliith studied experimentally the fate of anthrax bacilli when 
introduced directly into the trachea by injection through the larynx, or 
through a tracheotomy wound. From the results which he obtained he con- 
cludes that the bacilli can enter the circulation through the bronchial mu- 
cous membrane, and that the juice-canals and lymphatics are the channels 
through which the infection takes place. It appeared strange to the author 
that no bacilli could be found in leucocytes, but always only in epithelial 
cells. Final localization of the bacilli which have entered the circulation 
through the lungs takes place in distant organs by implantation upon the 
endothelial lining of the capillary vessels. 

Other experimenters affirm that if the anthrax bacilli are injected in 
moderate quantities into the circulation of animals, they disappear soon from 
the blood without having produced any pathogenic effects; but, if in ani- 
mals thus infected a contusion is produced in some part of the body, the 
bacilli pass out of the injured vessels into the connective tissue along with 
the blood, germinate there, and soon cause the formation of the character- 
istic inflammatory product, the disease becomes diffused, and the animals 
die of anthrax. Localization of the bacillus of tuberculosis affords an in- 
teresting subject for further experimental research and clinical study. 

The late distinguished Professor von Volkmann, from an extensive clin- 
ical experience, came long ago to the important and practical conclusion that 
a severe trauma seldom, if ever, gives rise to tuberculosis at the seat of in- 
jury; and, on the other hand, that in cases where tuberculosis develops in 
consequence of any injury, the trauma is always slight, sometimes almost 
insignificant. The experience of almost every surgeon will agree with these 
statements. Yolkmann maintains that the active tissue changes which fol- 
low a severe trauma during the reparative process counteract the growth 
and propagation of the bacillus. Luecke attributes to exposure to cold an 
important role in the causation of tubercular and other infective forms of 
inflammation, as he asserts that the sudden diminution of blood-supply to 
the cutaneous surface causes internal congestions, which favor the localiza- 
tion of pathogenic microbes in some one of the congested organs, otherwise 
predisposed to the specific inflammation. Schuller studied the localization 
of the tubercular virus experimentally in the same manner as others have 
studied the localization of pus-microbes. He inoculated animals with the 
products of tubercular inflammation, subsequently produced contusions and 
sprains of joints, and observed that localization usually occurred at the seat 



176 PRINCIPLES OF SURGERY. 

of injury. If the tubercular virus was introduced by inhalation, the same 
typical lesions occurred in the injured joints as when infection was practiced 
in a more direct manner. In all cases the product of the local joint-lesion 
corresponded with the character of the material introduced through some 
remote point. Surgeons are well aware of the danger of general infection 
following an injury to a part or an organ the seat of local tuberculosis, more 
particularly in cases of tubercular disease of joints treated by orisement force. 
Numerous cases are recorded where this procedure was followed within a 
few days by general miliary tuberculosis and a speedy death. In all cases 
where a local tuberculosis develops in consequence of an injury, we must 
take it for granted that the injured part contained the essential cause of the 
disease, the bacillus of Koch, and that the lesions caused by the trauma 
created the necessar}^ conditions for its reproduction; or, if the injured tis- 
sues at the time are sterile, that they serve the purpose of a locus minoris 
resistentice for bacilli which might reach them through the circulation. The 
frequency with which suppuration occurs without any visible infection- 
atrium has led bacteriologists to investigate with special care and diligence 
the localization of pus-microbes. 

Eosenbach ascertained, by numerous experiments, that acute suppura- 
tive osteomyelitis could only be produced by injecting pus-microbes directly 
into the circulation and by injuring the medullary tissue a few days before 
or after the inoculation. Kocher, Becker, and Krause repeated the experi- 
ments of Eosenbach, and came essentially to the same conclusions. Both 
Kocher and Eosenbach look upon the altered circulation in the injured part 
as the essential condition which determines localization of the pus-microbes 
floating in the blood-current; at the same time, they admit that the imme- 
diate tissue-lesions — haemorrhage and necrosis — may have the same effect. 
Upon the same theory, Kocher explains the occurrence of traumatic sup- 
purative strumitis in an hyperplastic struma. If non-septic pus is injected 
into the circulation of healthy animals in moderate quantities, no serious re- 
sults are produced, as the pus-microbes are soon eliminated through the 
kidneys. If, however, the pus-microbes attach themselves in the circulation 
to some foreign substance which prevents such elimination, suppuration will 
follow. A number of experiments made, among others by Eibbert, on the 
production of myocarditis and endocarditis in rabbits, have shown that ab- 
scesses can be produced in other organs if the pyogenic microbes are attached 
to foreign bodies which cannot pass through the pulmonary capillaries. 
Thus, Eibbert was able to produce myocarditis by using a cultivation of 
staphylococcus pyogenes aureus on potato, if he took the precaution, in re- 
moving the culture from the surface of the potato, to scrape off also the 
superficial surface of the potato itself. The particles of potato injected with 
the microbes determined suppuration by causing localization of the microbes, 



LOCALIZATION OF BACTEEIA. 177 

as the foreign bodies were too large to pass through the capillary vessels and 
were nol capable Of removal by absorption. 

The influence of a trauma in determining localization of microbes cir- 
culating in the blood is well shown by the experiments which have been 
made to produce, artificially, endocarditis in animals. 0. Eosenbach made 
the first experiments of this kind. He observed, in his experiments on ani- 
mals and in post-mortem examinations in cases of ulcerative endocarditis, 
rnicrobic emboli in the valves of the heart and in the infarcts of other organs, 
and classifies this affection with pyaemia. The more frequent occurrence of 
endocarditis in the left side of the heart than the right he explains by as- 
suming that the microbes find a better soil in the arterial blood, as when the 
affection occurs in the foetus during intrauterine life, when the blood in both 
sides of the heart is of about the same composition, the valves in both sides 
are affected with the same frequency. Orth and Wyssokowitsch found that 
staphylococci could be injected into the blood of a rabbit without apparent 
injury to it, but if before the injection a slight mechanical injury was in- 
flicted on one of the valves of the heart, typical endocarditis was at once 
produced. The injury was produced with a small rod, which was introduced 
into the jugular vein on the right side. The endocardial lesion always cor- 
responded to the seat of the injury. Similar results were obtained by 
Frankel and Sanger. 

Einne came to different conclusions in reference to injured tissues serv- 
ing as a locus minoris resistentice in the causation of inflammation due to the 
presence of microbes. He injected pure cultures of the different kinds of 
pus-microbes directly into the circulation of animals, and found that, as a 
rule, no harm resulted. In rabbits he injected from 2 to 3 Pravaz syringefuls 
of unfiltered, distilled water, holding in suspension pure cultures, and, after 
repeating this dose several times, inflicted all kinds of subcutaneous lesions 
without causing suppuration. Only in a few instances were pyaunic metas- 
tases observed, and these occurred usually only in cases where undiluted 
gelatin cultures were used. In several dogs he made subcutaneous fractures 
and then injected large doses of cultures of pus-microbes, suspended in dis- 
tilled water, into the peritoneal cavity, but no suppuration occurred at the 
seat of trauma. In six rabbits he fractured the femur subcutaneously and 
then injected pure cultures into the jugular, or one of the auricular, veins, 
but only in one of them did osteomyelitis occur at the seat of fracture. In 
two experiments where he injected osteomyelitic pus diluted with distilled 
water the seat of fracture suppurated, and in these cases abscesses were also 
found in the heart-muscle and the kidneys at the autopsy. It is difficult to 
explain the discrepancy between the results obtained by Einne and the other 
experimenters who have been quoted, as the same kind of animals and in- 
oculation material were used, and the experiments were conducted in the 



178 PRINCIPLES OF SURGERY. 

same manner. The fact remains, and is abundantly vouched for by clinical 
experience, that a subcutaneous injury, if the tissues remain sterile, does not 
give rise to inflammation, and that many inflammatory processes are estab- 
lished immediately or soon after an injury, and in the inflammatory product 
the presence of pathogenic bacteria can be demonstrated by microscopical ex- 
amination, cultivation, and inoculation experiments. A number of well- 
authenticated cases of osteomyelitis after simple subcutaneous fracture have 
been recorded where the infection could be traced to a slight peripheral sup- 
purative lesion. The same can be said of many cases of suppurative osteo- 
myelitis which occur without fracture, where the exciting cause can be re- 
ferred to some slight injury, or exposure to cold, and the essential cause can 
be located in some pus-producing lesion in a distant part, and having no 
direct vascular connections with the suppurating medullary tissue. From 
a scientific and practical stand-point, it is important to recognize the ex- 
istence of local conditions in the tissues created by a trauma, or antecedent 
pathological conditions, to explain the localization of floating microbes and 
the production of local affections by their uniform presence and constant 
pathogenic action. 

SECONDARY, OR MIXED, INFECTION. 

Antecedent pathological products may serve the same purpose in the 
body as a trauma in the determination of localization of pathogenic microbes. 
Suppuration in a tumor, or an hyperplastic gland with an intact cutaneous 
covering, indicates that in the tumor or swelling pus-microbes have been 
arrested, and that they have been deposited in a soil adapted to their ger- 
mination and the exercise of their pathogenic qualities. The atypical vas- 
cularization in tumors and the partial obstruction in the lumen of blood- 
vessels in inflammatory swellings cannot fail in creating conditions which 
determine filtration of bacteria-containing blood. If the preexisting patho- 
logical product is the result of a previous infection, and serves as a medium 
for localization of another kind of pathogenic microbes, we speak of the com- 
bined process due to the presence of two varieties of microorganisms as a 
mixed infection. The first positive proof of the existence of a secondary or 
mixed infection was furnished by Brieger and Ehrlich. These observers saw 
a malignant oedema develop at the point where musk was injected hypoder- 
mically in a severe case of typhoid fever. They found that in such cases a 
predisposition is established by an existing disease to the growth and repro- 
duction of microorganisms, which may have been previously present in the 
organism without producing any pathological lesions. 

Koch, in his article on "The Etiology of Tuberculosis," alludes to the 
occurrence of mixed infection, as he states that he saw at the same time 
bacilli and micrococci present in the same tubercular lesion. In reference 



SECONDARY, OB MIXED, INFECTION. 179 

to the occurrence of micrococci in tubercular deposits in the lungs and 
spleen, he explained their presence upon the supposition that they entered 
the circulation through ulcerations of the tongue, and that they became 
arrested in the capillary vessels, which had lost their normal resisting power 
by the tubercular process. Bumm maintains that in some patients secondary 
infection is a purely accidental occurrence, as, for example, a tubercular 
patient can be attacked with erysipelas; a lying-in woman suffering from 
gonorrhoea may become the subject of septic infection. 

Another and practically more important variety of mixed infection he 
speaks of where a more direct relation exists between the different microbes, in 
the sense that the one precedes the other and prepares the soil for the growth 
of the latter. These forms are characterized by being constantly associated 
with certain definite microbes. The pneumococcus may prepare the soil for 
fructification of the bacillus of tuberculosis or the microbes of suppuration 
in individuals that otherwise would have been immune to the action of these 
microorganisms. The gonococcus can also modify the mucous membrane 
of the genito-urinary tract in such a manner as to render easy the invasion 
of other pathogenic microbes. Gonorrheal infection of the vulvo-vaginal 
gland furnishes a good illustration. As long as the infection remains purely 
gonorrhoea^ the acute suppurative stage is followed by a. chronic stage which 
may last for several months, the swelling gradually subsides, and subse- 
quently atrophy and sclerosis of the gland follow. If, however, pyogenic 
infection is added to the gonorrhoea, the gland soon becomes enlarged and 
tender, and suppuration follows. In the abscess and its vicinity no gonococci 
can be found; the pus only contains pyogenic microbes, which exterminated 
the gonococci. Cystitis which accompanies gonorrhoea is, again, a variety 
of mixed infection. The stratified epithelium of the bladder is impenetrable 
to the gonococcus. 

According to Bumm, the cystitis is maintained by another species of 
microbe resembling the gonococcus, but differing from it by taking a dif- 
ferent staining. The gonococcus expends its action on the superficial layers 
of the mucous membrane exclusively. Suppurative parametritis following 
gonorrhoea is analogous to a gonorrhceal bubo, which is always caused by a 
secondary infection with pus-microbes. A valuable contribution to our 
knowledge of mixed infection has recently been made by Babes. His in- 
vestigations consist of a series of bacteriological studies of the tissues of chil- 
dren who died of infectious diseases. Within a few hours after death frag- 
ments of tissue were removed from different organs which, under strict anti- 
septic precautions, were imbedded in sterilized culture-material. In acute 
infectious diseases, such as diphtheria and scarlatina, cultures from the 
spleen, kidneys, liver, lungs, and blood yielded numerous colonies of strep- 
tococci, putrefactive bacteria, capsule cocci, more rarely staphylococci and 



180 PRINCIPLES OF SURGERY. 

various bacilli. Of special interest are Ms researches on the manner of local- 
ization and extension of the secondary invasion after different primary dis- 
eases. In 8 cadavers he found one or more species of bacteria in the internal 
organs. In a case of septic omphalitis he found the bacillus of green pus. 
In 6 cases of different forms of infectious disease the streptococcus pyogenes 
could be cultivated from the tissues, and only in 1 was the yellow pus-mi- 
crobe present in the culture. Various putrefactive bacilli were cultivated 
from 5 cases. In some instances he was able to demonstrate the point at 
which the different secondary invasions had taken place. Thus, in a case 
of sepsis after scarlatina, in which streptococci were found in every part 
of the body, a streptococcus pneumoniae was found in the lower portion of 
the left lung, while a number of foci in the upper portion of the opposite 
lung contained only bacilli. 

Frankel and Freudenberg cultivated from internal organs of 3 patients 
who had died of scarlatina the streptococcus pyogenes, and they maintain 
that the presence of this microbe is evidence that a secondary infection takes 
place through the diseased mucous membrane of the pharynx. 

Schnitzler, after having observed and carefully studied a number of 
cases, has come to the conclusion that syphilitic ulcerations of the larynx 
may pass into tubercular, as the syphilitic ulcer furnishes a good culture- 
soil for the bacillus of tuberculosis. 

Huber attributes the occurrence of suppuration and gangrene in croup- 
ous pneumonia, phlegmonous inflammation and suppuration in erysipelas, 
and suppuration in tubercular processes to secondary infection with pus- 
microbes. As the bacillus of tuberculosis and the streptococcus of erysipelas 
do not possess the property of converting leucocytes and embryonal cells 
into pus-corpuscles, suppuration, if it does occur in these diseases, can only 
he accounted for by admitting the existence of a secondary infection with 
pus-microbes. 

The important question presents itself whether, in cases of mixed in- 
fection, the two or more kinds of microbes enter the organism at the same 
time, or whether primary infection prepares the way for the entrance and 
fructification of the microbes which produce the secondary infection. Pus- 
microbes being present at all times and everywhere, and perhaps gaining 
entrance into the body more readily than others, it is very easy to under- 
stand why secondary infection by them is most frequently observed. Eosen- 
bach frequently found in pus more than one kind of pyogenic microbes. 
He often cultivated from the same pus two kinds of staphylococci, or one 
variety of staphylococci with streptococci. While antagonism among some 
bacteria has been shown to exist, others prepare the soil for the growth of 
a different variety, and in such instances it is not difficult to conceive that 
secondary infection is of frequent occurrence. For instance, an}' microbe 



ELIMINATION OF PATHOGENIC BACTEBIA. L81 

that will convert mature tissue into embryonal cells abbreviates and lightens 
the work of pus-microbes in converting fixed tissue-cells into pus-corpitscles. 

ELIMINATION OF PATHOGENIC BACTEEIA. 

Eaving described the different ways in which pathogenic bacteria enter 
the body, it now remains to show in what manner they are disposed of in the 
event no harm follows or the patient recovers from the disease which they 
produced. The probable existence of disease-producing microorganisms in 
the healthy body and the spontaneous subsidence of many infective processes 
make it important to consider the ways and means by which they are ren- 
dered harmless in the living body, or are removed by elimination through 
some of the excretory organs. In all infective processes in which life is not 
destroyed, and the products of inflammation do not find their way to the 
surface spontaneously or by operative treatment, the microbes are either de- 
stroyed in the blood and the tissues by phagocytosis or are eliminated 
through some of the excretory organs in an active state. The rapid disap- 
pearance of most microbes from the blood when injected into the circulation 
of healthy animals would indicate that an active warfare is instituted against 
them by the colored corpuscles of the blood, in which the microbes are de- 
feated; that is, destroyed. If some of the microbes pass through the capil- 
lary blood-vessels and come in direct contact with the fixed tissne-cells, a 
similar struggle ensues between them and the tissue-cells, and if the latter 
are victorious the microbes are destroyed. Successful phagocytosis must 
therefore be considered as the most efficient and desirable way of disposing 
of pathogenic bacteria after they have entered the tissues or the general cir- 
culation. But should phagocytosis prove unsuccessful in destroying the mi- 
crobes which have reached the blood, there is still another way in which the 
unassisted resources of the organism can deal with them successfully, viz.: 
elimination through one or more of the secretory or excretory organs. The 
critical discharges of the ancient authors — profuse sweating, diarrhoea, and 
copious secretion of urine — in the light of modern science have received a 
different significance, as they are now regarded as efforts of the vis medicatrix 
naturcc to throw off the cause which produced the disease: the pathogenic 
microbes and their toxins. The kidneys and the mucous membrane of the 
intestinal canal are the organs most concerned in the process of elimination. 
That microbes in an active state are eliminated by the kidneys is shown by 
various observations, and this is an important point to remember as prob- 
ably explaining certain cases of pyelitis occurring in patients who have never 
had any instrument passed, and in whom the urethra and bladder are per- 
fectly normal. The salivary glands, more especially the parotid, occasion- 
ally take part in the elimination of pus-microbes, thus offering an explana- 
tion of the not infrequent occurrence of abscesses in this gland after sup- 



182 PRINCIPLES OF SURGERY. 

puration elsewhere. The frequency with which the kidneys are affected in 
cases of tuberculosis furnishes an evidence that elimination of bacilli takes 
place through these organs. Philipowicz produced tuberculosis in animals 
by injecting urine taken from tubercular subjects into the peritoneal cavity. 
Neumann found the specific microbes in the urine in cases of typhus, sep- 
ticaemia, and pyaemia. In a case of acute endocarditis and osteomyelitis he 
cultivated from the urine the staphylococcus pyogenes aureus. He asserts 
that the microorganisms which circulate in the blood localize in the capil- 
lary vessels of the kidney, where they often cause minute multiple lesions 
without implication of the entire parenchyma of the organ. Through the 
altered tissues some of the microbes enter the tubuli urinif eri, and are washed 
away with the urine. Philipowicz found bacilli in the urine in anthrax and 
glanders. Schweiger has shown conclusively, by his bacteriological re- 
searches, that the urine from scarlatinal patients is contagious; for varicella, 
typhus recurrens, and malaria the same holds true. Schweiger regards all 
kidney-lesions occurring in the course of infective diseases of microbic origin. 
To prove that microbes pass through the kidneys, he cultivated a bacillus 
which Eeimann discovered in the pus of ozaena. This bacillus is stained an 
intense-green color in a culture of gelatin and agar after twenty-four hours. 
A culture of this bacillus was diluted with a physiological solution of salt and 
injected directly into the circulation. The experiments were made on a dog, 
cat, and rabbit. A certain length of time intervened between the injection 
and the appearance of bacilli in the urine, as though, somewhere on their 
way, an obstacle had been met with. At first only isolated bacilli were found 
in the urine, but later on they appeared in larger numbers. Bacteriological 
examinations of milk have shown that different kinds of pathogenic bacteria 
are eliminated through the mammary gland. Von Eiselsberg demonstrated 
by cultivation experiments the presence of staphylococcus pyogenes aureus 
in the sweat of a pyaemic patient, and after death he found the same microbe 
in the blood of different organs. The chapter on "Bacteria" would not be 
complete without at least alluding briefly to what is known in reference to 

DIRECT TRANSMISSION OF PATHOGENIC BACTERIA FROM PARENTS TO FCETUS. 

That many of the infectious surgical diseases are hereditary has been 
admitted by the best authorities for a long time, and many theories have 
been advanced to explain their transmission from parents to child. The 
modern views on this subject may be narrowed down to two suppositions: 

1. Transmission from parents to child of a predisposition to certain diseases. 

2. Direct transmission from parents to foetus of the essential cause of the 
disease. The supposed hereditary predisposition is interpreted as meaning 
some congenital anatomical or physiological defects in the tissues which 
render the organism unduly susceptible to the action of post-natal microbic 



TRANSMISSION OF PATHOGENIC BACTERIA PROM PARENTS TO FOETUS. 183 

infection. The existence of minute anatomical defects of blood-vessels, 
lymphatic vessels and glands, connective-tissue spaces, etc., has been ad- 
vanced in explanation of a greater liability of infection with floating mi- 
crobes, which enter the circulation after birth. 

An inherited defective vital resistance on the part of the tissues to the 
action of bacteria is also considered by many in the light of a congenital 
influence in the causation of disease. The above-mentioned conditions are 
recognized, but no satisfactory, demonstrative, or experimental proofs of 
their existence have as yet been furnished, and yet the immunity of some 
animals to certain diseases cannot be explained in any other way than in 
attributing to the tissues anatomical or physiological properties which pro- 
tect the organism against the action of certain microorganisms which, in 
other animals not so protected by inherited qualities, produce a serious or 
fatal disease. Clinical observation also teaches us that a great difference 
exists among different persons in reference to the degree of susceptibility to 
the same form of infection. In many persons, for instance, inoculation with 
a pure culture of tubercle bacilli would be a perfectly harmless procedure; 
in some it would be followed by a localized tubercular process which, in the 
course of time, might heal spontaneously; while in a few, rendered more 
susceptible to this form of infection by hereditary or acquired causes, in- 
oculation with the same number of bacilli would be followed by a severe form 
of local tuberculosis, soon to be followed by regional and general dissemina- 
tion and death. The same can be said of nearly all, if not all, infectious 
diseases. If their existence has not oeen demonstrated, we are, nevertheless, 
forced to accept the influence of certain as yet unknown conditions inherent 
in the tissues, and which are often traceable to a congenital cause or causes 
which favor or resist post-natal microoic diseases. During the last few years 
some progress has been made in showing that hereditary diseases, in many 
instances at least, are due to a more direct cause: transmission from parents 
to foetus of the essential cause of the disease, — pathogenic microbes. Al- 
though our knowledge of the intrauterine origin of microbic diseases is as 
yet imperfect, there can be no doubt that future study and research will clear 
up many dark points and furnish satisfactory demonstrative explanations 
of the direct and indirect hereditary influences in the causation of disease. 
It is well known that small-pox, measles, and scarlatina are directly trans- 
missible from mother to foetus. Numerous well-authenticated cases of these 
diseases occurring in newborn children have been recorded. Lebedeff reports 
a case of premature birth which occurred eight days after the mother had 
recovered from erysipelas. The child died ten minutes after birth, and the 
author found Fehleisen's streptococcus in the lymphatic vessels, in the dis- 
eased skin, and in the umbilical cord, but none in the placenta. The author 
believes that the streptococci were transported from the lymphatic vessels 



184 PRINCIPLES OF SURGERY. 

of the lower extremities of the mother through the lymphatics of the uterus 
into the placental vessels, and from the maternal into the foetal circulation. 
Ahlfeld and Marchand report the case of a woman who presented no symp- 
toms of disease except a moderate pallor and tympanitic distension of the 
abdomen. After a normal labor she gave birth to her second child; eight 
hours after delivery the patient died in collapse, for which no cause could 
be found. The autopsy revealed^ anthrax as the cause of death. The child 
died four days after birth, from the same cause. The mother, as was later 
ascertained, contracted the disease in sorting horse-hair, and the child was 
infected directly through the placental circulation. Sangalli found the 
bacilli of anthrax in the blood of a foetus from a woman who had died of 
anthrax. In opposition to Golzi and others, he affirms that the transmission 
of the disease from mother to foetus could only have taken place by the 
passage of the bacilli or spores from the maternal to the foetal circulation 
through the placental vessels. Xetter reports a carefully-observed case of 
direct transmission of the diplococcus of pneumonia from mother to foetus. 
The mother was a Yl-para, pregnant eight months, when she was attacked 
with croupous pneumonia, which terminated on the seventh day in recov- 
ery. On the ninth day after the attack she was delivered of a living child. 
The child died on the fifth day after birth. The autopsy revealed lobar 
pneumonia involving the right upper lobe, double fibrinous pleuritis, peri- 
carditis, suppurative meningitis, and otitis media on both sides. Bacterio- 
logical examination of the different inflammatory products, as well as of 
the blood taken from the left ventricle, showed the presence of Frankel's 
diplococcus pneumonia?. One of the strongest evidences of direct trans- 
mission of pathogenic microbes from mother to foetus through the placental 
circulation is the often-quoted observation made by Johne. An eight 
months' foetus was taken from a cow the subject of advanced tuberculosis. 
Xo tuberculous products were found in the placenta or the uterus, but- in 
the lower lobe of the right lung of the foetus a nodule the size of a pea was 
detected, containing four caseous centres. The bronchial glands were tuber- 
cular. The liver contained numerous miliary nodules. All the lesions pre- 
sented, under the microscope, the characteristic histological structure of 
tubercle. Jani has examined the healthy sexual organs of nine phthisical 
patients for tubercle bacilli. Xo bacilli were found, in any of these, in the 
semen from the vesicula? seminalis, but. on the other hand, in 5 out of 8 
cases, a few were found in the testicle, and in 4 out of 6 in the prostate 
gland. He further examined two women who died of pulmonary phthisis, 
the ovaries in both presenting negative results. In one case of chronic pul- 
monary phthisis, with extensive intestinal tuberculosis, he examined the 
Fallopian tubes, and found tubercle bacilli. He believes that the tubercular 
virus can be transmitted from parents to offspring in one of two ways: 



TRANSMISSION OV PATHOGENIC BACTERIA FROM PARENTS TO FC3TUS. 185 

1. Through the semen of the male. 2. Through the migration of bacilli into 
the uterus from the abdominal cavity. The frequency with which the 
Fallopian tubes are the scat of tubercular lesions makes it more than prob- 
able that the ovum, on its way from the ovaries to the uterine cavity, is in- 
fected with bacilli. It also requires no stretch of the imagination to under- 
stand how the spermatozoa in the testicle or on its way to the vesiculse 
seminalis can be contaminated with bacilli, and thus the disease directly 
transmitted from father to foetus. 

That syphilis is a microbic disease can no longer be doubted, and that 
it is one of the diseases which is most frequently transmitted from parents 
to offspring is well known. 

That pathogenic microorganisms may exist in the blood of apparently 
healthy mothers without doing any harm is well illustrated by children who 
have been born suffering from suppurative osteomyelitis, while the mothers, 
through whose blood only the microorganisms could have come, showed no 
evidences of disease. Kosenbach reports such a case in his article on acute 
osteomyelitis. Transmission of microbic diseases through the placental cir- 
culation has been made the subject of experimental inquiry. Strauss and 
Chamberland experimented on guinea-pigs to prove that intrauterine trans- 
mission of anthrax from mother to offspring is possible. G-ravid animals 
were inoculated with the virus of anthrax, and the foetuses examined im- 
mediately after death. Blood taken from the cavities of the heart and liver, 
examined under the microscope, never showed bacilli. Cultivation experi- 
ments were made with the foetal blood in veal-bouillon, and these proved 
that in some instances the blood of all foetuses from the same mother con- 
tained bacilli, sometimes from the same litter all cultures remained sterile, 
while in some the blood of only one foetus would yield a positive result. 
From these experiments the authors came to the conclusion that the tissues 
of the placenta offer no insurmountable obstacle to the passage of the bacil- 
lus of anthrax from the maternal into the foetal circulation. Ivoubassoff 
came to more positive results in his experiments. In all of his experiments 
the foetuses of the infected animals contracted the disease in utero. He also 
found that time played an important role as far as the number of bacilli in 
the foetus was concerned, as, the longer the period which intervened between 
the inoculation and the death of the mother, the more numerous were the 
bacilli in the foetal organs, showing that the migration of microbes from the 
maternal to the foetal side of the placenta is continuous. Inoculation with 
attenuated virus proved that intrauterine transmission took place more 
slowly. Inoculation of gravid animals with a very strong culture nearly 
always proved fatal to the foetuses. Most all authors agree that, when ex- 
travasations or other pathological processes occur in the placental attach- 
ment, the direct entrance of microbes from the maternal into the foetal cir- 



186 PEINCIPLES OF SUEGEEY. 

culation is not only possible, bnt a probable occurrence. Abnormality of 
the placental circulation must, therefore, be recognized as a condition which 
favors the occurrence of hereditary microbic disease. Both clinical observa- 
tion and experimental research leave no room for doubt that in some infectious 
diseases, at least, heredity is traceable to direct transmission of the specific 
microbes, either by means of transportation by the spermatozoa to the ovum 
or by their entrance through the thin wall which separates the maternal from 
the foetal circulation. It is no more difficult to explain the migration of mi- 
crobes through such a thin septum than their transportation from one tis- 
sue to another and from organ to organ in other parts of the body, more 
especially as the anatomical conditions for mural implantation in the 
placental vessels are most favorable for such an occurrence. 



CHAPTER VII. 



Necrosis. 



Xecrosis, gangrene, mortification, and sphacelus are terms used syn- 
onymously to indicate the death of a part. English and American writers 
have usually restricted the meaning of the word necrosis to death of bone, 
while the remaining terms were used to express the same condition affecting 
the soft tissues. Recently a sharp distinction has been made between ne- 
crosis and gangrene from an etiological stand-point, according to which 
necrosis is said to have taken place when the circulation and nutritive 
changes in a part have completely ceased to be followed by gangrene as soon 
as saprophytic bacteria invade it and give rise to putrefaction. Death of 
bone will never be described as gangrene, and the moist putrefactive form 
of gangrene of the soft tissues will, in all probability, be never designated 
by the term necrosis. Xecrosis of bone takes place in the same manner and 
results from the same causes as gangrene of the soft parts, and on this ac- 
count there does not appear to be sufficient reasons to apply different terms 
to identical processes occurring in different anatomical structures; and yet 
by long usage they have become so intimately associated with the anatom- 
ical character of the part affected that it is difficult, for the present at least, 
to drop either. In modern literature we speak of necrosis of the soft tissues 
when the dead structures do not undergo putrefaction; that is, when this 
process takes place in the internal organs not readily accessible to putre- 
factive bacteria, or when it involves external parts and is unattended by 
putrefaction. In its extent necrosis varies greatly; it may involve an entire 
limb, an entire organ, or may be limited to a single cell. As a physiological 
process it occurs everywhere in the tissues, being limited, however, to indi- 
vidual cells incident to the wear and tear of the body, the pulling down and 
building up of the tissues, the cells that are lost being replaced by the nor- 
mal process of regeneration. A simple, numerically-increased cell-necrosis, 
without normal restitution, leads to atrophy: necrosis atrophica. When all 
the cells of a part undergo death simultaneously, the circulation correspond- 
ing to the area of dead tissue is arrested completely, and with this absolute 
ischaemia, plasma-circulation, and all functions are, of course, completely 
suspended: a serious pathological condition, a total necrosis, has occurred. 

ETIOLOGY. 

Xecrosis is a condition, not a disease. As a symptom, it represents a 
local condition which has been brought about by different causes. The most 
frequent causes of necrosis are the following: — 

(187) 



188 PRINCIPLES OF SURGERY. 

Inflammation. — Inflammation may produce necrosis in two different 
ways: 1. Exudation and transudation take place so rapidly that complete 
stasis is produced by the extravascular pressure. 2. The bacterial cause of 
the inflammation is present in such large quantities that the vitality of the 
tissue is destroyed directly from this cause. If during an acute inflamma- 
tion the capillary walls undergo such serious alteration that within a few 
hours or days the connective-tissue spaces become so densely packed with 
the corpuscular elements of the blood that the plasma-circulation is greatly 
impeded or completely arrested, the primary inflammatory product en- 
croaches upon the capillary vessels to such an extent as to completely arrest 
the already sluggish circulation. If such a copious and rapidly-forming in- 
flammatory exudate give rise to complete stasis over a considerable area, the 
extent of the resulting necrosis will correspond to the district deprived of 
the requisite blood-supply. The same bacteria which produce inflammation 
frequently, if present in sufficient quantities, also cause cell-necrosis. Ogston 
maintains that the staphylococci invade the tissues in the form of dense, 
round masses, which advance like clouds of a dense vapor, and, coming in 
contact with the tissues, induce necrosis, the cells, nuclei, and intercellular 
substance being changed into a homogeneous, wax-like substance before 
purulent liquefaction occurs. On the other hand, the streptococci of sup- 
puration invade the intercellular spaces, the nuclei of the cells remaining 
visible. Bonome found the staphylococcus pyogenes aureus in such meta- 
static and broncho-pneumonic foci which presented a gangrenous character. 
He maintains that the staphylococcus at first produces in the lungs a ne- 
crosis by its multiplication, and that suppurative inflammation follows later 
around the necrotic tissue. Putrefaction of the dead tissue develops in con- 
sequence of the entrance of saproplrytic bacilli through the bronchial tubes. 
He verified these assertions by experiments. He obtained pure cultures of 
the yellow coccus from such pulmonary foci made by parenchymatous pul- 
monary injections, and succeeded in producing artificially identical lesions 
in the lungs of animals. The same result was obtained by the intravenous 
introduction of small particles of elder-pith impregnated with pure cultures 
of the yellow staphylococcus. The gangrenous foci produced by emboli con- 
taminated with the yellow coccus presented a characteristic appearance. 
The centre of such foci, at an early stage, is composed of necrotic tissue and 
remnants of dead leucocytes. The dead tissue is surrounded by a granular 
zone, which is again inclosed by a hemorrhagic zone, and beyond this an 
area of catarrhal pneumonia. The staphylococci occupy the central portion 
and from here invade the granular zone, where putrefactive bacteria are also 
found. The pus-microbes do not reach the hasmorrhagic zone, or the tissues 
the seat of catarrhal pneumonia. As Bonome was unable to produce gan- 
grene of the lung, either by parenchymatous injections of other bacteria, 



ETIOLOGY. 189 

as the pneumococcus or microsporon septicum, or by aseptic emboli of elder- 
pith, he natural lv came to the conclusion that the gangrene resulted from 
the specific ctl'cct of the yellow coccus. He compares gangrene of the lung 
with furuncle of the skin from an etiological stand-point. There can be no 
doubt that the primary effect of pus-microbes, when brought in contact with 
living tissue, under certain circumstances, is to produce necrosis before suffi- 
cient time has elapsed for parenchymatous inflammation to become estab- 
lished. This occurs in gangrene of the lung, furuncles, carbuncles, and 
endocarditis bacterial staphylococcica. In the ordinary connective-tissue ab- 
scess, however, the connective-tissue cells undergo the ordinary inflamma- 
tory changes before they are converted into pus-corpuscles, and if gangrene 
occur it is owing as much to mechanical obstruction of the circulation caused 
by a copious exudate as to the local toxic effects of the pus-microbes and 
their toxins. This difference in the action of pus-microbes on the tissues 
depends largely upon the rapidity with which they multiply at the point of 
primary localization. If the microbes are rapidly reproduced, the chemical 
substances "which they produce in the tissues are present in such large quan- 
tities that they destroy the cell-protoplasm, and cell-necrosis takes place as 
the result of their primary action; if the microbes multiply with less rapid- 
ity, their effect on the tissues is less severe, and parenchymatous inflamma- 
tion is produced instead of necrosis. Bonome used large quantities of pus- 
microbes in his injections, and the infected emboli caused circulatory dis- 
turbances, which only could favor rapid reproduction at the point of pri- 
mary localization. Passet and Liibbert repeated his experiments, but used 
more diluted cultures, and probably on this account they were never suc- 
cessful in producing gangrene of the lung, while they frequently observed 
the development of a pulmonary abscess. The centre of a furuncle, as well 
as a carbuncle, is occupied by a mass of dead connective tissue, which later 
becomes detached by suppurative inflammation. The connective tissue in 
these cases is killed by the bacterial cause of the suppurative inflammation, 
which, toward the periphery, appears to become mitigated; so that, behind 
the suppurating zone, a wall of granulation tissue is established which limits 
further extension of the disease. 

Specific Bacteria. — All bacteria which can produce an inflammation 
sufficiently severe to completely arrest circulation can become an indirect 
cause of necrosis. Among these can be included the pus-microbes and the 
bacillus of anthrax. The necrosis which occurs regularly almost in every 
case of anthrax is probably due to the intensity of the inflammation result- 
ing from the presence of the anthrax bacillus, to secondary infection with 
pus-microbes, or to the combined effect of both microbes. The absence of 
necrosis in artificially-produced anthrax, when pus-microbes are excluded by 
the strictest aseptic precautions, does not prove that the anthrax bacilli 



190 PEINCIPLES OF SURGERY. 

possess no necrotic effect on the tissue, as in such instances death follows 
so soon that not sufficient time intervenes between the inoculation and the 
death of the animal for the local inflammation to terminate in necrosis. 
Necrosis is, however, much more likely to occur if the anthracic infection is 
complicated by the presence of pus-microbes. It is well known that certain 
chemical substances have the power to produce cell-necrosis independently 
of their action to excite inflammation. Digitoxin, a poisonous principle of 
digitalis, is one of these. The primary effect of this substance on the tissues 
is to produce cell-necrosis. We should expect that some of the toxins possess 
similar properties. Orthmann made some very interesting experiments in 
this direction with pus-microbes. He inoculated both corneae in rabbits by 
making a puncture with a needle infected with a pure culture of the strep- 
tococcus pyogenes. One of the eyes was irrigated for ten minutes with a 
warm physiological solution of salt, by using an apparatus constructed for 
this special purpose. In the eye not thus treated a suppurative keratitis was 
initiated by the leucocytes from the conjunctival sac reaching the infected 
field, while in the cornea treated by irrigation the streptococci invaded the 
vascular spaces, and, multiplying with great rapidity, produced by their ac- 
cumulation dilatation of the spaces and necrosis of the fixed tissue-cells. 

In most of these cases the central necrosis led to perforation of the 
cornea and complete destruction of the eye. As the corneal corpuscles in 
the necrotic area had lost their nuclei and the parenchyma-cells showed no 
signs of inflammation, we cannot escape the conclusion that cell-necrosis 
was induced by the direct action of the toxins, elaborated by the masses of 
streptococci in the vascular spaces. The most conclusive proof of the de- 
structive effect of toxins on the tissues has been furnished by the great mas- 
ter and founder of modern bacteriology, Eobert Koch. In his experiments 
on septicaemia in mice he found, besides bacilli, a micrococcus in the neigh- 
borhood of the place of injection. Of the numerous kinds of bacteria con- 
tained in the putrid fluid used for injection, only the fine bacilli upon which 
the induction of the septicaemia depended and the chain cocci found a suit- 
able soil in the mouse, while all the rest perished. The chain coccus was 
never found in the blood, but only in the tissues at the seat of infection. He 
found it exceedingly difficult to isolate it from the bacillus. At last he 
succeeded in cultivating it in the field-mouse, which, as experiments proved,, 
is immune to the bacillus of septicaemia. The chain coccus injected into the 
subcutaneous tissue of the ear of the field-mouse invaded the tissues slowly, 
causing paleness and death of the cells without extravasation. The microbe 
entered and plugged the capillary vessels, but never found its way into the 
general circulation. Examination of the specimens showed that progressive 
gangrene occurred in advance of the microbes, hence could have occurred 
only by the action of toxins diffused through the tissues ahead of the mi- 



ETIOLOGY. 



]!)! 



crobie invasion. Intlammation of the fixed tissue-cells occurred around the 
zone of gangrene, and all leucocytes which reached the infected field per- 
ished. If the same animal was inoculated at the root of the tail, gangrene 
occurred and spread in a central direction, and resulted in death on the third 
day. The microbe did not change in its morphology or pathogenic prop- 
erties after passing through a series of inoculations. Both Ogston and Eo- 
senbach are of the opinion that the chain micrococcus with which Koch 
produced progressive gangrene in the field-mouse is identical with the strep- 
tococcus pyogenes. Baumgarten is of the opinion that microbes can produce 




Fig. 83. — Experimentally-produced Growth of Streptococci in Centre of Cornea of 
Rabbit. Horizontal Section. X 40. A, normal cornea; B, central necrotic portion, corre- 
sponding in outline to the star-shaped streptococcic culture. {Baumgarten.) 

necrosis not only by the production of a tissue-poison, but also by causing 
decomposition and by the assimilation of material necessary for cell-nutri- 
tion. The explanation advanced by Koch more than twenty years ago, how T - 
ever, appears more rational: "Introduced by inoculation (chain cocci) into 
living animal tissues, they multiply, and as a part of their vegetative process 
they excrete soluble substances, which get into the surrounding tissues by 
diffusion, and when greatly concentrated, as in the neighborhood of the 
micrococci, this product of the organisms has such a deleterious action on 
the cells that these perish and finally disappear completely. At a greater 



192 PRINCIPLES OF SURGERY. 

distance from the micrococci the poison becomes more diluted and acts less 
intensely, only producing inflammation and accumulation of lymph-corpus- 
cles. Thus it happens that the micrococci are always found in the gan- 
grenous tissue, and that in extending they are preceded by a wall of nuclei 
which constantly melts down on the side directed toward them, while on 
the opposite side it is as constantly renewed by lymph deposited afresh." 

An almost identical form of gangrene, as experimentally produced in 
the field-mouse by Koch, is occasionally met with in man. It is known as 
progressive gangrene, and is so called from its most conspicuous clinical 
feature: rapid extension. Before antiseptic surgery was known it frequently 
developed in cases of compound fracture and compound dislocation of large 
joints, and often proved the direct cause of loss of limb or life, or both. Two 
cases came under my own observation where it occurred after extirpation of 
carcinoma of the breast, in one without, and in the other with, removal of 
the axillary glands.- In both cases the first symptoms appeared on the third 
day. The general symptoms were those of intense sepsis, while the local 
conditions resembled first what used to be called phlegmonous erysipelas. 
An erysipelatous blush appeared at the margins of the wound and extended 
rapidly in all directions, accompanied by infiltration of the deep tissues. 
The gangrene attacked the tissues first involved and followed the course of 
the phlegmonous inflammation. In spite of the most energetic local and 
general treatment, both patients died at the end of the first week. Eosen- 
bach describes two cases that came under his care. In one the disease started 
from a small wound of a finger, the process finally extending to the lower 
extremities, with death on the sixth day. In the second case the local lesion 
appeared first as a red induration, around which cedema developed rapidly, 
the skin covering the part presenting a reddish-blue discoloration before 
gangrene set in. This patient had an eruption of the skin over the whole 
surface of the body which resembled the rash of scarlatina. From the lesions 
of both of these cases Eosenbach cultivated upon peptone-meat gelatin the 
streptococcus pyogenes. Ogston calls this affection erysipelatoid-wound gan- 
grene, and always found in the gangTenous tissue the streptococcus. Gan- 
grene produced by staphylococcus, the same author calls sloughing inflam- 
mation or inflammatory mortification. The streptococcus of erysipelas never 
produces gangrene, and when this complication occurs in this disease it is 
always a positive indication that secondary infection with pus-microbes has 
taken place. 

Putrefactive Bacteria. — Xecrosis occurring from the action of any other 
microbes than those of putrefaction is not attended by any disagreeable odor 
or other evidences of putrefaction, and, if limited in extent and protected 
against the invasion of saprophytes, the dead tissue, if limited in quantity, 
may be completely removed by absorption. Putrefactive bacteria feed on 



ETIOLOGY. L93 

dead tissue, and in the absence of such they are comparatively harmless. 

Putrefaction only takes place in moist gangrene, and is always caused by 
the invasion of dead tissue with one or more species of saprophytes. Pro- 
gressive gangrene, complicated by secondary infection with saprophytes, is 
characterized by the formation of gases which give rise to emphysema. 
Progressive gangrene with emphysema is one of the most fatal of all wound 
complications, as the ptomaines elaborated by the saprophytic bacilli greatly 
increase the danger from sepsis. Sulphureted hydrogen is one of the gases 
formed during putrefaction of necrosed tissue. Rosenbach cultivated from 
the infected tissues, in two cases of progressive gangrene with emphysema, 
a saprophytic bacillus with spores. Hauser cultivated from putrefying or- 
ganic substances one or more kinds of the proteus, the proteus mi rah His 
(Zerikeri) and vulgaris. 

Trauma. — The vitality of a part is completely destroyed if a trauma 
is sufficient in intensity to arrest the circulation completely, and of such a 
character and extent as to render a return of it impossible. Such injuries, 
for instance, are caused by the passage of a car-wheel over a limb, where the 
skin often remains intact, while all of the deeper tissues are completely 
crushed. A blow against a part of the body where only a thin layer of tissue 
is interposed between the skin and an underlying bone may crush the sub- 
cutaneous tissue to such an extent as to preclude the possibility of a return 
of an adequate circulation, and necrosis follows as an inevitable result. 
Deep-seated contusions from the application of external violence are often 
attended by circulatory disturbances, which necessarily result in necrosis. 
Xecrosis of ganglion-cells following contusion of the brain affords a good 
illustration of the occurrence of traumatic necrosis at a distance from where 
the force was applied. In such cases the cells are separated from all their 
anatomical connections by the trauma, and either undergo calcification or 
are removed by absorption. If such a contused area become the seat of a 
subsequent infection, suppuration or putrefaction can occur, according to 
the location of the part injured, infection taking place with pyogenic mi- 
cribes or saprophytes. In the so-called railway-spine the cell-necrosis fol- 
lowing a contusion of the spinal cord leads to remote, central, and peripheral 
disturbances. A trauma may be of such a nature as to inflict an injury not 
incompatible with the integrity of a limb, but may create conditions which 
subsequently result in complete obliteration of a main artery. If an artery 
is subjected to serious pressure or traction, the intima gives way and the 
lumen of the vessel is subsequently obliterated by the formation of a throm- 
bus at the seat of injury. In such a case the artery is at first permeable, 
and the distal pulsations are unaffected until the lumen of the vessel is 
narrowed and finally completely obliterated by the formation of a thrombus. 
The late Professor von Wahl has called attention to an early and important 



194 PRINCIPLES OF SURGERY. 

symptom in these cases, the detection of which enables the surgeon to recog- 
nize the vessel injury before the appearance of the positive peripheral symp- 
tom, — viz., a bruit, — which can be heard by placing the stethoscope over the 
seat of injury. The vessel injury in such cases is of serious import, as the 
contusion of the soft tissues which is usually also present retards or prevents 
the formation of an adequate collateral circulation, and gangrene occurs in 
consequence of complete interruption of the arterial circulation. A vein 
may be injured in a similar manner, and the venous stasis following oblitera- 
tion by a thrombus may become a determining cause of gangrene of a limb, 
the vitality of which has been otherwise impaired by the injury. 

Decubitus. — Prolonged uninterrupted pressure causes necrosis by in- 
terrupting the circulation. Tight bandaging and pressure of splints have 
often been productive of gangrene. Bed-sores are liable to form in patients 
suffering from acute infectious diseases, and in persons suffering from fract- 
ure of the spine, or disease of the spinal cord; also, in aged obese persons 
treated in the recumbent dorsal position for fracture of the neck of the 
femur. Decubitus is most prone to appear in consequence of pressure over 
bony prominences, and on this account we look for it in persons who are 
going through a long-enforced confinement in bed, first over the sacrum, the 
trochanteric regions, the spinous processes of the vertebrae, and the heels: 
parts most affected by the dorsal decubitus. The deleterious effect of press- 
ure is greatly aggravated by filthy surroundings, as under these circum- 
stances the necrosed tissue becomes the seat of infection with pus-microbes 
and saprophytic bacteria, which inaugurate a progressive gangrene and sep- 
sis, often constituting the direct cause of death. It is not unusual, in cases 
of septic decubitus, to find the whole sacrum exposed, and in one instance 
that came under the author's observation the spinal canal was opened and 
through the opening the cerebro-spinal fluid escaped, first clear, later puru- 
lent. This patient lived for several days after the cerebro-spinal fluid had 
commenced to escape, and before his death he presented symptoms which 
indicated that the meningitis had extended to the envelopes of the brain. 

Defective Arterial Blood-supply. — The aseptic ligature, combined with 
the aseptic treatment of wounds, has been the means of greatly dimin- 
ishing the frequency of gangrene after ligation of the principal arteries of a 
limb in their continuity. Gangrene usually occurred, not so much from the 
sudden interruption of the arterial blood-supply as from the septic inflam- 
mation following the operation, which interfered with the formation of a 
satisfactory collateral circulation. 

Ligation of Arteries in their Continuity. — Statistics of a number of 
years ago show that gangrene has followed ligation of the subclavian in the 
outer third in 9 per cent, of the cases reported; external iliac, 15 per cent.; 
common femoral, 11 per cent. The results after ligation of these vessels 



ETIOLOGY. 195 

have much improved since the introduction of the aseptic ligature. In a 
healthy person with normal blood-vessels there is but little danger of gan- 
grene following the ligation of the principal arteries of a limb with an 
aseptic ligature under aseptic precautions. Gradual obliteration of an artery 
by a thrombus is not attended by equal danger of the occurrence of gangrene 
as when the same vessel is suddenly and completely blocked by impaction 
from the arrest of an embolus, because collateral circulation is on a fair way 
of becoming established before the lumen of the vessel is completely closed, 
while in the latter case the demand on the collateral vessels is more urgent 
and sudden, and consequently the failure on their part to act as substitutes 
for the obliterated trunk is more frequent. Valvular disease of the heart, 
fatty degeneration of this organ, atheroma of the arteries, — in fact, all 
pathological conditions which diminish the vis a tergo, — are instrumental in 
the causation of gangrene, when from any accidental cause or operative 
interference the blood-supply to a limb has been diminished, or when the 
tissues are the seat of a progressive septic inflammation. Gradual diminu- 
tion of the arterial blood-supply generally gives rise to dry gangrene, as is 
the case in senile gangrene, while sudden interruption of the circulation 
through a large artery from the application of a ligature or the impaction 
of an embolus is usually followed by moist gangrene. 

Obstructed Venous Circulation. — Impeded venous circulation is fraught 
with as much danger, as far as the production of gangrene is concerned, as 
obstruction of the arterial circulation. Langenbeck was impressed with this 
fact so strongly that he recommended, if it became necessary to ligate one of 
the principal veins of an extremity near the trunk, to ligate at the same time 
the accompanying artery in order to guard against the evil results follow- 
ing ligation of a large vein. Aseptic surgery has minimized the danger 
of ligaturing veins, — for instance, the axillary or femoral vein, — and no sur- 
geon at the present time would deem it necessary, or even justifiable, to 
ligate the corresponding arteries simply for the purpose of preventing ex- 
cessive venous engorgement and of favoring the formation of an adequate 
venous collateral circulation. The same advantages which have resulted 
from aseptic operations for the timely formation of an arterial collateral 
circulation after ligature of an artery are secured for the maintenance of an 
inadequate venous circulation after the ligation of a vein. Venous obstruc- 
tion from pathological causes often proves more disastrous, as the causes 
which have brought about the formation of a thrombus frequently do not 
remain local, and the thrombus increases in length in both directions, thus 
rendering the formation of a collateral circulation a difficult, if not an im- 
possible, occurrence. As venous obstruction gives rise to oedema, gangrene 
— if it occur under these conditions — always represents the moist variety, 
and is usually accompanied by putrefaction. 



196 PRINCIPLES OF SURGERY. 

Heat. — Heat produces pathological conditions according to the degree 
of the temperature and the length of time a part is exposed to its action. A 
momentary exposure even to a high temperature produces only a burn of 
the first degree; that is, simply an active hyper semia and redness of the sur- 
face. If the part is exposed for a somewhat longer time the hyperemia is 
followed by a superficial inflammation and blisters form: a condition which 
is described as a. burn of the second degree. In such cases the necrosis is 
limited to the epidermis, which is detached from the papillary layer by the 
serous transudation. In burns of the third degree the deeper tissues are 
destroyed by the heat, and extensive necrosis is the result. Cohnheim de- 
termined that a temperature from o±° to 58° C. was sufficient to produce 
gangrene in the rabbit's ear. If he immersed the ear for a short time in 
water heated to this temperature, necrosis always followed. A somewhat 
lower temperature continued for a longer time produced the same effect. 
Heat produces necrosis by coagulating the cell-protoplasm, if its action is 
superficial; if it penetrate more deeply, the blood in the blood-vessels is 
coagulated, and necrosis of the tissues deprived of circulation in this man- 
ner follows as an inevitable result. Intestinal ulceration, in case of extensive 
burns, is also a necrotic process, caused by capillary obstruction with dead 
or dying blood-corpuscles derived from the burned district. It has been 
found experimentally that a temperature over -15° C. has a destructive effect 
on the blood-corpuscles. Welti ascertained that if the ear of a rabbit is 
kept immersed in water, gradually heated to 70° C, bleeding from the nose 
and hemoglobinuria followed: symptoms which he attributed to partial or 
complete obstruction of capillary vessels with the third corpuscle of the 
blood. 

Cold. — The action of cold in producing necrosis is closely allied to that 
of heat. Frost-bites are classified the same as burns. Cold, like heat, causes 
gangrene by producing cell-necrosis and vascular obstruction. 

Cohnheim produced gangrene of the rabbit's ear by exposing it for a 
short time to a temperature of 16° C. The length of time a part is exposed, 
either to heat or cold, exerts an important influence in determining the 
extent and depth of the subsequent gangrene. Gangrene resulting from a 
burn or exposure to cold remains dry and aseptic as long as the entrance 
from without of pus-microbes and saprophytes is prevented, but with mi- 
crobic invasion suppuration and putrefaction are established. 

Pancreatic Ferment. — Under certain conditions the pancreas undergoes 
acute fat-necrosis from the action of its own secretion. Katz and Winkler 
tied and divided the pancreatic duct, being careful not to injure the vessels. 
This experiment was made on fifty dogs, and they found fat-necrosis in all 
of them. Haemorrhage occurred almost always around the necrotic areas, 
and the necrosis was most marked in the neighborhood of the ligatures. 



ETIOLOGY. 197 

The necrosis was apparently due to the action of the fat-splitting ferment 
of the pancreas. 

Caustics. — Chemical substances which by their local action on the tis- 
sues produce extensive cell-necrosis are called caustics. Of these, the strong 
acids and mineral salts destroy cells by causing coagulation. The necrosed 
tissue, or eschar, resulting from their action is firm, and the contour of the 
cells is well preserved. The alkaline caustics, on the other hand, dissolve 
the tissue-elements, and the slough resulting from their application is soft. 
A peculiar form of necrosis of the maxillary bones occurs in persons ex- 
posed to the fumes of phosphorus. The most recent explanation of the oc- 
currence of necrosis of the jaws in persons employed in match-factories is 
to the effect that the phosphorus fumes in the mouth are transformed into 
phosphoric acid, and that necrosis of the hone is produced by the direct 
action of the acid on the bone and myeloid cells, while the periosteum re- 
mains intact and produces new bone. 

Ergot. — The prolonged administration of ergot in large doses is at- 
tended by the risk of causing gangrene. The gangrene from ergotism is 
always of the dry variety. It is generally believed that it is caused by the 
drug keeping up an angiospasm, which shuts off the full blood-supply to 
the peripheral portion of the extremities: the most frequent seat of the 
gangrene. Zweifel, of Erlangen, believes that the toxic effect of ergot results 
in a vasomotor paresis, and that the gangrene is due to defective innerva- 
tion. 

Raynaud's Disease. — Symmetrical gangrene, or Eaynaud's disease, is a 
form of ischaemia due to contraction of the arterioles. The arterial spasm 
may extend to arteries the size of the radial. Baynaud recommends the use 
of the constant descending current to the spine. 

Internal Necrosis. — In simple cell-necrosis the tissue-elements may 
have undergone no changes in form, but the cell-protoplasm has lost its 
vital properties and function has been completely arrested. Such cells pre- 
sent a cloudy appearance, and if the necrosis has resulted from a gTadual or 
sudden ischaemia the part affected presents a pale appearance. In the 
periphery of such a necrotic area the vessels become dilated and an hyper- 
amiic zone forms, in which the collateral circulation is to be established. If 
an artery in any of the internal organs is suddenly obliterated by the im- 
paction of an embolus, the tissues supplied by the closed vessels are deprived 
for a time, and perhaps permanently, of their blood-supply, and in conse- 
quence of this they become pale, while around the wedge-shaped infarct 
the vessels concerned in the formation of collateral circulation are distended 
to their utmost, and often yield to the increased intravascular pressure when 
extravasation of blood occurs. If the collateral circulation is not speedily 
established, necrosis of the tissues supplied by the obliterated vessel is the 



198 PRINCIPLES OE SURGERY. 

result. In mycotic cell-necrosis haryolysis — that is, dissolution of the cells 
— usually occurs. If the cell-membrane rupture and the contents of the 
cell escape, we speak of a haryorhexis. Absolute ischaemia of certain parts 
or cell territories continued for only one to two hours is sure to result in 
necrosis. If any portion of the brain, intestines, or kidney is deprived of 
blood-supply for this period of time, nutrition is completely suspended, and 
cell-necrosis follows as an inevitable consequence. Litten ligated the renal 
artery in animals, and found, at the end of an hour and a half to two hours, 
the renal epithelia in a state of necrosis. Limited necrosis of the parenchyma 
of the brain may give rise to focal symptoms by which the lesion cannot 
only be recognized, but often accurately located. Infarcts of the kidney 
can frequently be diagnosticated by a careful chemical and microscopical 
examination of the urine. A similar condition in the lungs gives rise to cir- 
cumscribed catarrhal pneumonia, which can be recognized by a careful phys- 
ical examination of the chest. Ulcer of the stomach, the result of a circum- 
scribed necrosis, is attended by a complexus of symptoms pointing directly 
to the seat and nature of the lesion. Necrosis in internal organs is not often 
followed by putrefaction, as saprophytes seldom reach the dead tissue. Ne- 
crosis of the lungs is sometimes followed by gangrene, by the entrance into 
the necrosed tissue of putrefactive bacteria from the respiratory passage. 
Gangrene of External Parts. — As it is often impossible to recognize 
during life a limited cell-necrosis in the internal organs by the symptoms 
presented, this subject has been briefly disposed of, but the symptomatology 
of external gangrene will receive a more thorough consideration. It might 
appear that the recognition of the existence of gangrene of any of the ex- 
ternal parts would require no special care or erudition. But this is not so. 
It is true that, when gangrene is fully developed, when all the characteristic 
symptoms are present, a correct diagnosis can be made on first sight. But 
cases occur where it is exceedingly difficult to determine whether the part 
affected is dead or only in a state of inflammation. In illustration of this 
the author will only allude to the difficulties which surround the surgeon in 
many cases of herniotomy, when he has to determine whether it is justifiable 
to return a portion of intestine that has been strangulated for some time if 
he simply rely on the appearance of the intestine. The intestine presents a 
dusky, almost black, appearance, and the casual observer might come to 
the conclusion that it is gangrenous and treat it as such, when, in fact, a 
more careful observation will soon reveal the fact that the circulation is not 
completely arrested, and that it is safe to return it. 

SYMPTOMS. 

(a) Pain. — Sudden, severe, often excruciating pain in a limb is the 
first indication which announces the occurrence of embolism in one of the 



SYMPTOMS. 199 

large arteries. In the lower extremity the embolus is often arrested at the 
bifurcation of the popliteal artery, but the pain extends along the whole 
limb, from the toes to the groin. The sudden anaemia is the cause of the 
pain. In senile gangrene the gradual ischasmia caused by the atheromatous 
degeneration of the arteries gives rise to pain and a sensation of numbness, 
which precede the gangrene for weeks or months. Acute inflammation re- 
sulting in gangrene is attended by intense pain from the very beginning; 
the pain abates, as a rule, with the occurrence of gangrene. Pain may be 
absent at the seat of necrosis, and referred to some other part or locality. 
In strangulated hernia the patient often suffers little or no pain at all in 
the swelling, but complains of a periodical pain in the region of the um- 
bilicus. The absence of pain and tenderness over the region of a hernia 
speaks rather for than against the presence of gangrene. Osteomyelitis is 
attended by severe pain, which is diminished or subsides with the escape 
of the products of inflammation from the bone into the surrounding tissues. 
In cases of intestinal obstruction the cessation of pain, with continuance of 
the symptoms of obstruction, is an indication that gangrene has occurred. 

(b) Tenderness. — The pain elicited by pressure is a more important 
symptom in the diagnosis of necrosis than spontaneous pain. As long as the 
part suspected to be necrotic is sensitive to the touch it is a sign that necrosis 
has not taken place. To test the sensation of a part it is advisable to resort 
to puncture with an aseptic needle. Absence of pain and all sensation on 
puncturing the tissues with a needle is often the best argument to convince 
the patient and friends that necrosis has occurred. 

(c) Temperature. — The difference in the temperature of a part threat- 
ened with gangrene has given rise to the expressions hot and cold gangrene. 
If gangrene follow an acute inflammation the local temperature remains 
high until other evidences of gangrene make their appearance, when the 
complete arrest of circulation and tissue-metamorphosis result in a sudden 
fall of the local temperature. In gangrene following atheroma, thrombosis, 
embolism, and ligation of arteries the local temperature is reduced before 
gangrene occurs. 

(d) Pulse. — After ligation of the principal artery of a limb the sur- 
geon examines anxiously, from day to day, for the appearance of pulsation 
in the distal portion of the artery: an occurrence upon which depends the 
fate of the limb. The reappearance of the pulsation in the distal part of 
the artery is a certain indication that collateral circulation has become estab- 
lished, and that gangrene will not occur. With the appearance of distal 
pulsations the local temperature increases, and the diminished tissue-meta- 
morphosis is restored to its normal state. In embolism or thrombosis of a 
large artery the same disturbances in the peripheral circulation of the limb 
are observed as after ligation. By searching for pulsation in different parts 



2 00 PRINCIPLES OF SURGERY. 

of the limb the surgeon can often locate the thrombus or embolus. If, for 
instance, the embolus or thrombus is located in the terminal portion of the 
popliteal artery, pulsations of the femoral artery can be felt from Poupart's 
ligament down to the seat of obstruction, while no pulsations below this 
point can be felt until collateral circulation is established. Obliteration of 
an artery from pathological causes is prone to prevent the formation of an 
adequate collateral circulation by the growth, in both directions, of the 
thrombus or embolus. The pulse furnishes the most important means to 
follow from day to day the growth of the intravascular blood-clot. In senile 
gangrene a thrombus frequently forms in one of the smallest arteries and 
grows in a proximal direction, extending from the digital branches to the 
dorsalis pedis, to the anterior tibial, or from the plantar arteries to the poste- 
rior tibial, the popliteal, and finally the femoral. In such cases the arteries 
can be felt as firm cords, but pulsations are limited to the previous portion 
of the vessels. An embolus often becomes the centre of an enormous throm- 
bus, which seriously impairs the chances of preservation of the limb by the 
establishment of an early and adequate collateral circulation. When an em- 
bolus obstructs the popliteal artery, pulsations can be felt above this point, 
but they disappear with the extension of the secondary thrombus in a proxi- 
mal direction. 

(e) Swelling". — In moist gangrene the necrosed tissue imbibes moisture 
to a considerable extent, and the slough is larger than the tissue it repre- 
sents. The swelling is increased twice as much when gas forms in the tis- 
sues. In dry gangrene the parts shrink, become firmer, and instead of swell- 
ing there is diminution in their size as compared with their volume in a nor- 
mal state: a condition called mummification. 

(f) Emphysema. — The presence of emphysema in gangrenous tissue is 
a certain indication of the presence of gasogenic bacteria. The character 
of putrefaction depends on the kind of saprophytes which are present in the 
dear] tissues. The different kinds of proteus possess gas-producing proper- 
ties. The proteus, according to Hauser, appears in different forms, accord- 
ing to the chemical reaction of the soil mpon which it grows. On acid 
gelatin the culture consists of cocci and short bacilli: on alkaline gelatin 
it grows in the form of threads, vibrios, spirilli, etc. All these different 
forms of proteus growing in dead tissue exposed to the atmospheric air pro- 
duce sulphureted hydrogen. Hauser cultivated the proteus from ulcerating 
carcinomas and bed-sores. Chiari reports an interesting observation con- 
cerning the production of a septic emphysema and gangrene caused by the 
bacillus coli communis. The patient was suffering from diabetes and 
atheroma. The great toe was amputated for gangrene. Gangrene of the 
foot followed, which extended above the ankle. Gussenbauer amputated 
above the knee-joint. Gangrene of the stump, with extensive emphysema, 



SYMPTOMS. 201 

supervened, and the patient died a Jew days after the operation. The bacillus 
eoli communis was found m the affected tissues and the blood, and was 
cultivated in agar-gelatin and grape-sugar. The gasogenic properties of this 
jmicrobe were well shown in the cultures. All attempts to produce septic 
emphysema in animals with pure cultures failed, as the animals died of acute 
sepsis, hi the cases of progressive gangrene with emphysema examined 
bacteriologieally by Kosenbach, he found the bacillus saprogenes fcetidus. 
Emphysema is sometimes so marked that on percussion a tympanitic reso- 
nance is elicited. "When less in degree its presence can be readily recognized 
by pressure, which causes a crackling, crepitating sound. Hitzmann and 
Lindenthal describe a new anaerobic bacillus which they isolated in four 
of five cases of gangrene foudroyante. It is a large bacillus with rounded 
ends, staining by Gram's method, non-sporogenic, non-capsulated, and im- 
motile. It produces gas, both from carbohydrates and jDroteids, and is 
pathogenic for guinea-pigs, producing the same lesions as in man, while 
rabbits are refractory and mice frequently so. It is widely distributed in 
nature, and occurs in the intestinal canal. One of the gasogenic microbes 
which is now attracting a good deal of attention and which is often found 
in emphysematous inflammatory products is the bacillus aerogenes capsu- 
latus (Welch). Muscatello and Gangati claim that this bacillus is without 
pathogenic action in healthy tissues, but that it produces gaseous gangrene 
when it comes in contact with tissues of reduced vitality. It causes death 
from toxaemia, and post-mortem it spreads throughout the body. 

(g) Color. — If gangrene take place in consequence of interrupted arte- 
rial circulation, the part at first presents a preternaturally pale appearance 
until the first visible evidences of the actual occurrence of gangrene are an- 
nounced by a livid or lead color, at a point where the circulation has first 
been completely arrested. The lividity, when it is due to complete, irrep- 
arable capillary stasis, is not affected by pressure. Blisters containing a 
sanious fluid form at points where the deeper tissues have already undergone 
necrosis. As soon as the circulation has been completely arrested, tissue- 
metamorphosis is at once suspended, and the further changes are entirely 
of a chemical nature. The colored corpuscles of the blood undergo rapid 
disintegration; the coloring material is diffused through the dead tissue and 
into the interior of the bulla?. The black color of gangrenous tissue is pro- 
duced by sulphuret of iron: a combination of sulphureted hydrogen and 
haemoglobin. 

(h) Condition of Tissues. — The condition of the dead tissues will de- 
pend on the cause of the necrosis. In dry gangrene they become firmer by 
evaporation of the fluids. In moist gangrene they imbibe fluids and undergo 
maceration, becoming soft and friable. In moist gangrene a fetid, sanious 
fluid escapes from the dead tissue. Adipose tissue in a condition of gangrene 



202 PRINCIPLES OF SURGERY. 

undergoes speedy disintegration, and free globules of fat are mixed with 
the sanious discharge. Maceration of tissue is considered by Bavoth as the 
most important condition in determining the presence of gangrene in cases 
of strangulated hernia. He maintains that if the tissues of the intestinal 
wall can be readily separated and teased asunder with a dissecting forceps 
there can be no doubt that gangrene has occurred. This maceration, how- 
ever, takes place only some time after the circulation has ceased, and is 
entirely absent in necrosis of bone, cartilage, and tissues well supplied with 
elastic elements, as the arteries. In determining the presence of gangrene 
in strangulated hernia, where any doubt as to its presence exists in the mind 
of the operator, it is much better to liberate the strangulated loop, draw it 
forward, and irrigate it every few minutes with a hot solution of salt, which 
will stimulate the sluggish circulation, and will soon furnish reliable proof 
of the actual condition of the vessels and the tissues. Mechanical stimula- 
tion of the intestinal wall is also a valuable diagnostic measure, as, if gan- 
grene has occurred, no amount of irritation will excite peristaltic action, 
while with the restoration of the impeded circulation the muscular fibres 
will respond to irritation. 

(i) Odor. — jSTecrosed tissue does not emit any unpleasant odor unless 
it has become invaded with putrefactive bacteria. The almost unbearable 
stench which attends extensive moist gangrene is always the result of putre- 
factive changes. Dry gangrene is odorless. In acute inflammatory affections 
of the lung, where a communication has been established between the in- 
flammatory focus and the bronchial tubes, the presence or absence of foetor 
is of great diagnostic value, as its presence speaks in favor of gangrene and 
its absence indicates an abscess. 

(j) Mummification. — By this term we mean a drying up of a gan- 
grenous soft part from the loss of fluids which it contains by evaporation. 
It is a state of preservation of dead tissue while still attached to the living 
body. It can only occur if the dead tissue is exposed to the atmospheric 
air, and on this account it is always absent in necrosis of internal organs. 
Mummification can only take place where putrefaction is absent, and, there- 
fore, is most frequently met with where gangrene is first limited, and in- 
creases gradually hj an aggravation of the causes which produce gradual 
diminution of the arterial blood-supply, as in cases of senile gangrene. 

(k) Line of Demarcation. — The line of demarcation is the line where 
the farther extension of gangrene has been arrested by an adequate collateral 
circulation and a wall of living granulations. Back of this line of demarca- 
tion, on the side of the living tissues, there is to be found an hyperbaric 
zone, which precedes and attends the regenerative process, and by which the 
farther extension of the gangrene is prevented. In septic gangrene the line 
of demarcation marks the limits of the area of infection, while in aseptic 



SYMPTOMS. 203 

gangrene it indicates the point where the vascular conditions answer the 
physiological requirements of the part. 

(1) Elimination of Gangrenous Part. — Spontaneous elimination of a 
gangrenous part is of frequent occurrence. The necrotic tissue may be dis- 
posed of in a spontaneous cure in three different ways: 1. Absorption of 
dead tissue. 2. Separation of necrosed part by granulation. 3. Separation 
of the sphacelus or sequestrum by suppuration. A limited quantity of 
necrosed aseptic tissue can be completely removed by absorption in the same 
manner as absorbable aseptic substances are removed when implanted in the 
tissues. This is the most desirable termination of gangrene, and takes place 
frequently in cell-necrosis of the internal organs. Such a disposal of aseptic 
necrosed tissue is also possible on the surface of the skin when the area does 
not exceed a square inch, and an aseptic condition is secured throughout. 
The capacity of the tissues to remove aseptic necrosed tissue is limited, and 
when the quantity of tissue surpasses this capacity the dead part is consid- 
erably diminished in size, and the balance is detached by the granulations 
which form at the line of demarcation, and is finally eliminated spontane- 
ously or by operation. Eepair after this manner of elimination is rapid and 
satisfactory. If infection with pus-microbes has taken place in the begin- 
ning of the lesion which has caused the necrosis, or, later, at the line of 
demarcation, separation of the slough takes place by means of a suppurative 
inflammation. In such cases the dead part is not diminished in size, and the 
healing, after its elimination, takes place more slowly, and the result, as a 
rule, is less satisfactory. Separation takes place very slowly in necrosis of 
bones, intermuscular connective tissue, and tendons, requiring often weeks 
and months before the dead tissue can be removed. 

(m) Liquefaction of Necrosed Tissue. — In internal necrosis where no 
putrefaction or suppuration takes place, and the amount of necrosed tissue 
exceeds the absorptive capacity of the surrounding tissues, liquefaction takes 
place, and months and years later the seat of necrosis is occupied by what 
appears, and has often been falsely described, as a cyst. This method of dis- 
posing of the dead tissue is observed most frequently in organs scantily sup- 
plied with connective tissue, as the brain and spinal cord and in adipose 
tissue. 

(n) Encapsulation. — A limited area of aseptic necrosed tissue, not 
amenable to absorption, is often rendered harmless by encapsulation. The 
surrounding living tissue throws out a wall of granulation-tissue which is 
converted into connective tissue, forming a capsule around the dead tissue. 
This method of disposal of dead tissues frequently occurs in the internal 
organs. A sequestrum occasionally becomes encapsulated after the interior 
of an involucrum has been rendered spontaneously, or by treatment, aseptic. 

(o) General Symptoms. — These will have reference to the loss of func- 



204: principles or surgery. 

tion caused by cell-necrosis in internal organs and sepsis in external necrosis. 
Function will be affected according to the location and extent of cell-ne- 
crosis. If cell-necrosis is of mycotic origin and general, it frequently be- 
comes a direct cause of death. If it is limited to a single organ, the symptoms 
will point to it as the seat of the disease. Limited areas of cell-necrosis, in 
most of the organs, may give rise to ill-defined or no symptoms whatever. 
and are then completely beyond the grasp of a correct diagnosis. The most 
important general symptoms of gangrene arise from the introduction into 
the general circulation from the gangrenous part of soluble toxic substances. 
As this subject will be treated of more extensively in the chapter on "Sep- 
ticaemia," it will suffice here to make the broad, but correct, statement that 
septicaemia complicates gangrene only when the dead tissues are infected 
with pus-microbes or putrefactive bacteria. Dry gangrene is, therefore, not 
attended by any danger of septic intoxication; while patients suffering from 
moist gangrene with putrefaction die, as a rule, not from the loss of tissue 
from gangrene, but from sepsis incident to the gangrene. Sepsis in gan- 
grene is usually of that variety which arises from the introduction into the 
circulation of preformed toxins, the symptoms subsiding with the removal 
of the cause, with the exception of those cases of progressive sepsis caused by 
infection with pus-microbes. 



CHAPTER VIII. 

Necrosis (continued). 

PATHOLOGICAL AND CLINICAL VARIETIES OF NECROSIS. 

The pathological and clinical classification of necrosis is based upon 
its causes, location, extent, and the age of the patient. The causes of 
necrosis have already been considered, and it has been shown that it results 
either from arrest of the circulation from purely mechanical causes or from 
the action upon the tissues of toxic, chemical, or thermal influences which 
destroy the protoplasm of the cells directly. The location of the necrosis 
is important to remember, as when it occurs in organs inaccessible to sapro- 
phytic microorganisms putrefaction never takes place; on the other hand, 
necrosis in parts accessible to atmospheric air is prone to be followed by 
putrefaction, with all the dangers which attach themselves to this condition. 
The extent of the gangrene has an important bearing on the prognosis, as, 
when the causes are such as to determine a circumscribed form of the dis- 
ease, life is not in danger, while the progressive form, with few exceptions, 
ends in death, in spite even of the most heroic treatment. The age of the 
patient often determines the form of gangrene, as, for instance, senile gan- 
grene is a disease of the aged, while noma, almost without exception, attacks 
only children. The simplest and an exceedingly common form of necrosis 
is what has been described by Weigert as 

Coagulation-necrosis. — This is essentially a cell-necrosis. It is called 
coagulation-necrosis because the tissues present the appearance of coagulated 
albumen, and also on account of the process resembling coagulation of the 
blood. Coagulation-necrosis is probably identical with, or, at any rate, 
nearly allied to, the hyaline degeneration of Eecklinghausen and fibrinous 
degeneration of E. Wagner. 

The chemical process which results in coagulation-necrosis is as yet 
imperfectly understood. Weigert, who was the first to describe this form 
of necrosis, maintains that the cell-protoplasm and, perhaps, all albumen- 
containing substances are converted by it into a substance resembling fibrin. 
Macroscopic-ally, tissues which have undergone this form of necrosis present 
a yellowish or whitish appearance, and are of variable consistence. Under 
the microscope the cells either appear unchanged in form or their place is 
occupied by thread-like fragments and granular material. Weigert lays down 
as the earliest change witnessed in a cell undergoing coagulation-necrosis 
disappearance of the nucleus, which is the case twelve to twenty-four hours 
after the process commenced. Fibrin is a product of coagulation-necrosis 

(205) 



206 PRINCIPLES OF SURGERY. 

of the blood. According to Alexander Schmidt, during the coagulation of 
blood the colorless corpuscles disappear; the product of their destruction is 
fibrin-ferment and fibrinoplastic material, which, with the fibrinogen of the 
plasma, form fibrin. Isolated cells destroyed by coagulation-necrosis ex- 
foliate, and are transformed into a homogeneous granular substance, which, 
according to circumstances, is removed hj absorption or becomes encapsu- 
lated. Cell-necrosis en. masse is often followed by calcification, and on sur- 
faces by ulceration. The transformation of a tubercular product into a 
cheesy mass is the result of coagulation-necrosis. As essential conditions 
for coagulation-necrosis to occur "Weigert enumerates: 1. Death of tissue- 
cells. 2. Presence of plasma-fluids. 3. Tissues must contain coagulable 
substances. An entire organ may be destroyed by coagulation-necrosis. 
Pale infarcts after embolism are products of this change. The so-called 
fibrin wedges, which were formerly regarded as decolorized blood-clots, 
consist of such tissues. At first the cells are normal in outline and 
appearance; later, the nuclei disappear and the cells break up into granu- 
lar masses. In the internal organs coagulation-necrosis is most fre- 
quently met with in the kidneys, spleen, typhoid deposits, tubercular 
lesions, the vicinity of mycotic foci, and in atheroma of the blood-vessels. 
In the parenchyma of organs it attacks the epithelial cells, while the 
connective tissue remains intact. On mucous surfaces it is represented by 
the diphtheritic and croupous exudations. While the chemical processes which 
take place in coagulation-necrosis cannot as yet be explained satisfactorily, there 
can be no doubt that this form of necrosis is nearly always, if not always, of 
mycotic origin, and it must be regarded practically in the light of a bacterial 
necrosis. Klebs describes the same condition as karyolysis, learyorhexis, and 
vacuolar degeneration. He claims that early disappearance of the nucleus is 
not an essential, but an accidental, condition. In a case of pseudodiphtheria 
Klebs found the bacilli between cells devoid of nuclei, and only in the 
centre of the necrotic patch did he find bacilli within the cells; from this 
he concluded that karyolysis is due to the action of chemical products of 
the bacilli. In the second group of mycotic necroses the process differs as 
in typhus. Here the necrotic centre, which contains no cells, is surrounded 
by a zone, in which both cells and nuclei are also absent, but which contains 
a large number of chromatin bodies, lying free in the tissues. As these 
bodies are found in a location where the cells and nuclei have been destroyed, 
it can hardly be doubted that they represent remnants of these structures. 
According to Wolmkom and Graessle, these bodies are liberated by rupture 
of the nuclear envelope. This method of cell-destruction is called learyo- 
rhexis. A third form of cell-necrosis is vacuolar degeneration, in which the 
change is initiated in the protoplasm itself. This must not be mistaken for 
cell-cedema. In vacuolar degeneration the protoplasm ruptures, and the 



PATHOLOGICAL AND CLINICAL VARIETIES OF NECROSIS. 207 

nuclei of epithelial cells, which line a hollow viscus, are liberated, as Lang- 
hans observed in this form of cell-necrosis in the kidney. The cell ruptures 
on account of increased intracellular pressure, and the process well deserves 
the name plasma-rhexis. This form of cell-destruction was formerly consid- 
ered a post-mortem change. For the sake of simplicity it is advisable to sub- 
stitute for the different forms of cell-necrosis described by Klebs the gen- 
eral term, coagulation-necrosis, devised by Weigert. 

Necrobiosis. — This is a term applied by Yirchow to the spontaneous 
wearing out of living parts. Death of isolated cells is a physiological process 
as long as they are replaced by new cells of the same tissue type. Necro- 
biosis occurring on a more extensive scale is a pathological condition, and 
is etiologically identical with coagulation-necrosis. The term can be used to 
signify circumscribed cell-necrosis without reference to its etiology or mi- 
nute morbid anatomy. 

Progressive Gangrene. — This form of gangrene is always of bacterial 
origin. The microbe most frequently found in the tissues is the streptococ- 
cus pyogenes. It occurs most frequently after wounds which open up a large 
surface of loose connective tissue, as in compound fractures, compound dis- 
locations, excision of the breast, with removal of axillary glands and extirpa- 
tion of large, fatty tumors. The streptococcus pyogenes invades the con- 
nective-tissue spaces rapidly, somewhat after the manner of diffusion of the 
streptococcus through the lymphatic vessels. Much of the connective-tissue 
necrosis results from the direct action of the pus-microbes and their toxins 
on the cells. The necrosis of the skin is no indication of the extent of the 
disease in the deeper tissues. The infection is initiated by a chill, and the 
fever which follows resembles severe sepsis from other causes. If infection 
occur during the operation, or at the time of accident, the first symptoms 
may be looked for within forty-eight to seventy-two hours. If suppuration 
has occurred it is diminished with the appearance of septic infection, and 
the discharge becomes thinner and sanious. Lymphangitis frequently ac- 
companies the deep-seated phlegmonous inflammation. Gangrene appears 
in the tissues first affected, and spreads rapidly along the connective tissue. 
Xot only the gangrene is progressive, but also the attending septicaemia . 
The larger the area of necrosis, the more extensive the field for the growth 
of pus-microbes and putrefactive bacteria. Progressive gangrene is an ex- 
ceedingly dangerous form of infection, and unless treated by heroic meas- 
ures at an early stage is sure to lead to a speedy fatal termination. 

Progressive Gangrene, with Emphysema. — Etiologically this form of 
gangrene is identical with the preceding plus secondary infection with ga- 
sogenic oacteria. The necrosed tissue answers the purpose of a nutrient me- 
dium for saprophytic microorganisms, which not only generate gas which is 
diffused through the dead tissues, but the soluble toxic substances which thev 



208 PRINCIPLES OF SURGERY. 

elaborate in the necrotic area are absorbed into the circulation: an occur- 
rence which gives rise to toxaemia. Emphysema almost always extends far 
beyond the limits of the visible gangrene, but its presence is a sure indica- 
tion of the extent of the infection in the deep-seated tissues. Progressive 
gangrene, with emphysema, is the most fatal form of gangrene, and only in 
exceptional cases will the surgeon succeed in warding off a certain fatal ter- 
mination by early operative interference. In both kinds of progressive gan- 
grene the part is swollen, cedematous, the skin presenting first a livid, bluish 
color, which afterward shades into a greenish or reddish-black hue. Bullae, 
containing a reddish serum, form at points where the gangrene is spread- 
ing. Besides sulphureted hydrogen, butyric and valerianic acids, ammonia, 
sulphur, etc., are some of the many chemical products of putrefaction. The 
rapidity with which progressive gangrene, with and without emphysema, 
spreads has led the French authors to apply to it the term gangrene foudroy- 
ante. 

Moist Gangrene. — Progressive gangrene is necessarily a moist gangrene, 
as bacteria cannot germinate without moisture. All forms of mycotic gan- 
grene are forms of moist gangrene. All necroses in the interior of the body 
belong to this variety. The moisture of the dead tissue is due to imbibition 
of the oedema-fluid, and consequently moist gangrene is apt to follow vas- 
cular conditions in which there is some impediment to the return of venous 
blood, as in cases of obstruction in a large artery, and more especially when 
a large vein has become obliterated by a thrombus. Moist gangrene is at- 
tended by all the dangers incident to putrefaction. In this form of gan- 
grene the line of demarcation is the seat of suppurative inflammation. 

Dry Gangrene. — In dry gangrene the dead tissue undergoes mummifica- 
tion, and on this account the soil is unfitted for the germination of putre- 
factive bacteria. Dry gangrene is usually the result of a trauma, the action 
of a chemical substance, or it follows a gradually-diminishing blood-supply. 
In senile gangrene it follows in consequence of a gradual diminution of 
blood-supply, owing to atheromatous degeneration of the arteries, while the 
return of venous blood remains unimpaired. Dry gangrene is often an asep- 
tic gangrene. If no infection take place with pus-microbes, the line of de- 
marcation is formed by granulation-tissue, and the gangrenous part, if small, 
is absorbed, or if this is impossible on account of its size it is separated by 
the granulations. If suppuration take place this occurs at the junction of 
the dead with the living tissues. Dry gangrene is usually not attended by 
any general symptoms, and all attempts to remove the dead tissue should be 
postponed until the line of demarcation has formed. 

Senile Gangrene. — This is the gangrene of the aged, or, rather, it is the 
gangrene which is caused by atheromatous degeneration of the arteries. 
Senile marasmus, in the form of atheromatous degeneration of the arteries, 



PATHOLOGICAL AND CLINICAL VARIETIES OF NECROSIS. 



209 



may occur in persons less than 40 years of age, and is often absent in octo- 
genarians. Senile gangrene always occurs in parts where the circulation is 
feeblest; consequently it usually commences in one of the toes. If the ne- 
crosed tissue remain aseptic, the rapidity of the extension of the gangrene 
depends on the condition of the blood-vessels. It may remain limited to 




Fig. 84.— Dry Gangrene of Foot. Line of Demarcation well Defined. (After Lebert.) 



one toe, or it may extend from toe to toe, and then creep along the dorsum 
or plantar surface of the foot, or on both sides simultaneously, and extend 
quite rapidly to the leg as far as the knee. Usually the disease extends along 
the course of one of the principal arteries, and extends later to other parts 
of the foot in consequence of greater embarrassment of the arterial and 



210 PRINCIPLES OF SURGERY. 

venous circulation. If infection in the vicinity of the necrosed tissue with 
pus-microbes take place, a suppurative inflammation may follow senile gan- 
grene, which will give rise to a progressive and rapidly-fatal form of the dis- 
ease. In the dry form of senile gangrene the tissues mummify, are firm, 
and perfectly black in color. . In the moist variety the parts present the same 
appearances as in progressive gangrene. If a line of demarcation form, the 
separation of the dead from the living tissues requires an unusually long 
time, as the circulation is enfeebled to such an extent that tissue-prolifera- 
tion takes place very slowly. 

Diabetic Gangrene. — It is a well-known clinical fact that persons suf- 
fering from diabetes are very prone to be attacked by gangrene. The reasons 
for this are as yet unknown. Gangrene occurring from trivial causes in per- 
sons presenting the appearances of usual health, and in whom no evidences 
of atheromatous degeneration of the arteries can be detected, should awaken 
the suspicion of the existence of diabetes, and no time should be lost in 
making a careful examination of the urine. A strictly antidiabetic diet has 
often resulted in arresting further extension of the gangrene. Konig has 
found that after amputation for gangrene in diabetics the quantity of sugar 
in the urine is diminished. 

Decubitus. — Gangrcena per decubitum literally means gangrene from 
pressure. It occurs in consequence of pressure from splints, bandages, and 
the prolonged recumbent position in bed, especially in persons suffering from 
fracture of the spine, or acute infectious diseases attended by great impair- 
ment of the circulation. Pressure without infection is productive of dry 
aseptic gangrene, but usually gangrene from this source is complicated by 
infection with pyogenic or putrefactive bacteria, or both. If gangrene from 
pressure is inevitable, it is apparent that its occurrence should be met by 
timely precautions for the purpose of preventing accidental infection. Gan- 
grene from splint pressure can be prevented by interposing between the 
splint and bony prominences a thick cushion of salicylated cotton. Bed- 
sores should be prevented by changing the position of patient frequently and 
protecting the parts most exposed to the ill effects of pressure with fenes- 
trated rubber cushions, by enforcing absolute cleanliness, and by keeping the 
skin in a healthy condition by applications of spirituous lotions. Both in 
gangrcena per decubitum and senile gangrene the necrosis is caused by im- 
pairment or complete suspension of the capillary circulation. 

Noma. — Noma, cancer aquaticus, is characterized by rapid, gangrenous 
destruction of the cheek, which usually commences some distance from the 
lips. This disease is exceedingly rare in this country, but quite prevalent in 
the large cities of Europe. It attacks exclusively children, occurring most 
frequently between the ages of 3 and 8 years. Healthy children seldom suffer 
from this disease; it either appears in badly-nourished, cachectic subjects 



PATHOLOGICAL AM) CLINICAL VARIETIES OF NECROSIS. 211 

or it occurs as a complication of some of the eruptive fevers or typhus. In 
reference to the etiology of noma, little is known. The almost constant oc- 
currence of the disease in a distinct part of the cheek and its limitation to 
one side of the face would indicate that it might be the result of some nerv- 
ous disturbance. It is, however, more probable that it is a form of mycotic 
necrosis. A few observations on the bacterial origin of noma have been 
made. Lingard found in the tissues a long bacillus, which he believed was 
the cause of the disease. In gangrenous stomatitis in the calf, which affects 
this animal at particular seasons of the year, he found bacilli wdiich are very 
similar in appearance to those present in noma in man. On cultivation they 
present characters which render them easily distinguishable from other bac- 
teria, and on inoculation of these microorganisms into the calf a gangrenous 
stomatitis is again produced. 

Eanke's investigations on noma led to the following conclusions: Dif- 
ferent forms of gangrene resulting from noma can unquestionably occur 
spontaneously in children who have a tendency to disease of this character; 
that is, without infection from contact. The frequent occurrence of noma 
in public institutions, and the apparent preference of the disease for local- 
ization upon the mucous membrane of the different openings of the body, 
suggest that the origin of it may be referred to the invasion from without 
of microorganisms. In the zone of tissue contiguous to that which has un- 
dergone necrosis may be found cocci which in number appear like a pure 
culture. At the periphery of the necrotic zone which has been invaded by 
cocci the connective tissue is found in a state of active proliferation. The 
entire condition is suggestive of the tissue-necrosis in field-mice, which is 
caused by a chain coccus, described by Koch. Up to the present time the 
specific nature of the cocci which Eanke found in noma tissues has not been 
shown. Schimmelbusch has examined one case for bacteria, and found ba- 
cilli, often in pairs and sometimes in long filaments, growing along the 
boundary-line of the living tissues. The bacillus grew upon gelatin without 
liquefying it, and pure cultures injected into rabbits caused abscesses. Un- 
doubtedly, further bacteriological research will prove that noma is a my- 
cotic necrosis, and that the dead tissue, like in other forms of necrosis, is sub- 
sequently invaded with putrefactive bacilli. The disease commences as a 
circumscribed livid spot upon the surface of the mucous membrane of the 
mouth, and a corresponding portion of the cheek in its entirety is indurated. 
Soon the color of the affected mucous membrane becomes darker, and the 
skin, which at first presented a dusky appearance, is turned nearly black, 
and the epidermis is elevated in a blister, which afterward is turned into a 
black eschar. With the separation of the gangrenous part an opening in the 
cheek is left without any sign of a line of demarcation. The gangrene 
spreads in all directions, and, if not arrested spontaneously or by the use of 



212 PRINCIPLES OF SURGERY. 

energetic measures, often destroys the entire cheek. The disease is not lim- 
ited to the soft tissues, but attacks the maxillary bones, often causing ex- 
tensive necrosis and loss of teeth. The gangrene seldom extends beyond the 
median line in the lips, and the tongue usually remains free. In the major- 
ity of cases the disease is fatal. Death is preceded by symptoms of intense 
sepsis, with secondary septic inflammation of some of the internal organs, 
especially the intestines and lungs. In some cases a gangrenous affection of 
the genital organs occurs, which in every respect resembles the affection of 
the cheek. In case recovery takes place, the defect caused by the necrosis has 
to be restored by a plastic operation. 

Hospital Gangrene. — Gangrcena nosocomials, ulcer ative-wound dipli- 
theriiis, only occurs as an infection of wounds, and, as the name hospital 
gangrene indicates, is seldom met with outside of large unsanitary hospitals. 
Before wounds were treated antiseptically, it occurred as a frequent compli- 
cation after operations or open injuries in most of the European hospitals. 
It was prevalent among the wounded during the Civil War. Thanks to the 
labors of Lister and his followers, it has now disappeared almost completely 
among civilized nations. The simple fact that this dreadful disease has been 
almost completely expunged from the oldest and most infected hospitals by 
the aseptic treatment of wounds furnishes conclusive proof of its mycotic 
origin. Unfortunately, practical bacteriology was born too late to take ad- 
vantage of the numerous opportunities to study the etiology of this form of 
wound infection. A feature of this disease of unusual bacteriological in- 
terest is the fact that it attacks not only recent wounds, but also wounds 
covered by healthy granulations. A healthy granulating surface is consid- 
ered as a good, if not an absolute, protection against the ordinary pathogenic 
bacteria which infest wounds, but the microbe of hospital gangrene mani- 
fests no such discretion. "Whether hospital gangrene is due to a specific 
pathogenic microbe or to exceptional pathogenic power acquired by some 
one of the common bacteria which infest suppurating wounds is not known. 
The latter view is entertained by Sternberg. H. Yincent describes a bacillus 
which he claims is the specific cause of this disease. He discovered it in the 
membranous deposit on the ulcerating surface. The organism is not 
found in the blood nor could it be cultivated on any of the usual nutrient 
media. Inoculations in the lower animals failed to reproduce the disease; 
hence he is inclined to believe that its pathogenic action is confined 
to man. The first evidence of the appearance of hospital gangrene is the 
formation of a yellowish, pultaceous mass upon the surface of a recent wound 
or upon a granulating surface. This mass can be readily wiped away, with 
the exception of the lowest layers, which are firmly attached to the surface. 
The skin in the immediate vicinity of this deposit becomes red and inflamed, 
and is soon displaced by the same material. The original wound assumes a 






PATHOLOGICAL AND CLINICAL VABIETIES OF NECROSIS. 213 

yellowish-gray appearance, and is rapidly enlarged by the extension of the 
destructive process. Within three days to a week the wound is enlarged to 
double its original size. In this, the pulpous, form of the disease extension 
toward the depth of the wound is slow, as fascia and muscles offer consid- 
erable resistance to its progress in this direction. In the ulcerative form of 
hospital gangrene the wound or granulation surface becomes the seat of an 
ichorous discharge, and the tissues undergo rapid destruction by molecular 
disintegration. The ulcerative form of hospital gangrene makes more rapid 
progress than the pulpous. Although these two forms occur as distinct 
affections throughout, combinations of the two have been observed. Hos- 
pital gangrene, in preference, attacks small wounds, as punctures, the bites 
of leeches, abrasions, blistered surfaces, etc. Many authors have been in- 
clined to believe that diphtheritic inflammation of a wound and hospital 
gangrene are identical, but, so far, no positive proof of such identity has been 
furnished. The clinical course of both of these processes is nearly the same, 
but etiologically and pathologically the differences are apparent. Heine 
claimed that he observed hospital gangrene where the wounds were infected 
with virus from patients suffering from genuine diphtheria, and again he 
saw genuine diphtheritic lesions of mucous membranes in patients who were 
exposed to the contagium of hospital gangrene. The general symptoms in 
the beginning of an attack of hospital gangrene are not severe. The patient 
complains of a loss of appetite and a general feeling of malaise. In old per- 
sons, children, and debilitated subjects, it may prove fatal without the oc- 
currence of special complications. One of the great dangers which attend 
hospital gangrene, especially the ulcerative form, is secondary haemorrhage. 
During the pulpy degeneration or molecular disintegration of the tissues 
vessels are implicated, and a sudden haemorrhage from a large vessel fre- 
quently leads to a rapidly-fatal termination. The large vessels show an 
unusual resistance to the destructive effect of hospital gangrene, but not in- 
frequently they give way, especially if the disease attack a stump after am- 
putation. Septic intoxication is never so well marked in hospital gangrene 
as in diphtheritic affections of mucous membranes. Billroth believes that 
hospital gangrene is caused by a specific microorganism which is only repro- 
duced under certain atmospheric conditions: hence the appearance of the 
disease formerly in an epidemic form. Clinical observations leave no doubt 
that the disease is carried from one patient to another by means of sponges, 
instruments, hands, etc. 

Perforating Ulcer of Stomach and Duodenum. — These ulcers follow cir- 
cumscribed necrosis of the wall of the stomach or duodenum, caused by a 
diminished arterial blood-supply of a limited vascular district. That these 
ulcers are of vascular origin is shown by their shape and direct relation to 
an arterv. The defect is in the form of a cone, the base bein°- directed 



214 PRINCIPLES OF SURGERY. 

toward the lumen of the viscus, and the apex corresponds with a small artery 
which must have been partially or completely obstructed before the necrosis 
occurred. These ulcers are sometimes multiple, and in the stomach they 
are found in preference along the lesser curvature. After interruption of 
the arterial circulation the wedge-shaped, ischemic, necrosed portion is re- 
moved by the action of the gastric juice, and the ulcer is made. As per- 
forating ulcer of the stomach or duodenum never occurs in cases of ulcera- 
tive endocarditis, but selects in preference young females, the causes of vas- 
cular obstruction must be of a local nature. The sphacelus shows molecular 
deca}f, but no trace of inflammation. Perforating ulcers of the stomach and 
intestines are of interest to the surgeon, because in case of perforation their 
treatment has been brought within the legitimate sphere of successful ab- 
dominal surgery. The more frequent occurrence of perforation is prevented 
by circumscribed plastic peritonitis, which seals the defect or establishes an 
adhesion between the affected portion of the organ and some adjacent sur- 
face. 

Perforating Ulcer of Foot. — This ulcer follows a localized necrosis of 
the foot, which is supposed to be, in part, at least, the consequence of 
vasomotor disturbances, to which are added impediments to the circulation 
and frequently infection with pathogenic microorganisms. This ulcer is 
remarkable for the regularity of its outline, looking as though a piece had 
been cut out with a punch. The defect corresponds to the shape of the de- 
tached necrosed tissue. The necrosis affects all of the tissues of the part in 
which it occurs, not even sparing the bones and articulations of the foot. 
The dissections of Duplay, Morat, Fischer, and others leave no doubt that 
this strange ulcer originates from necrosis following degeneration of the 
nerves of the affected region. Infection with pus-microbes follows the 
necrosis: an occurrence which renders the treatment more intractable. 

Ergotin. — One of the effects of chronic ergot intoxication is sym- 
metrical dry gangrene. Bread made of flour containing ergot has not in- 
frequently occasioned, in Europe, fatal epidemics, usually attended with dry 
gangrene. As before stated, the gangrene following the prolonged admin- 
istration of this drug is either the result of a chronic angiospasm or of a 
paralytic effect of the drug on the peripheral nerves. 

Prognosis. — The prognosis in a case of gangrene should be based on the 
etiology, location, and extent of the disease which caused the gangrene. 
The existence of complications must also be taken into careful consideration. 
Acute, rapidly-spreading gangrene, irrespective of the causes which may 
produce it, must always be considered as an exceedingly grave condition. 
Mycotic progressive gangrene, with and without emphysema, unless treated 
early and heroically, proves fatal almost without exception, death resulting 
from septicaemia. Gangrene following obliteration of the principal artery 



PATHOLOGICAL AND CLINICAL VARIETIES OF NECROSIS. 215 

of a limb would result in death, in the majority of cases, unless a fatal sepsis 
is prevented by early amputation. Necrosis of the entire or greater part of 
important internal organs is incompatible with life from the greatly dimin- 
ished or completely suspended function of the affected organs. The prog- 
nosis, so far as life is concerned, in cases of senile gangrene, is rendered ex- 
ceedingly grave when the gangrene spreads rapidly, in consequence of an 
ascending arterial thrombosis, or thrombophlebitis, and life is in imminent 
danger when the gangrene due to diminished blood-supply is complicated by 
a rapidly-spreading suppurative inflammation, or if septic intoxication arise 
from invasion of the moist necrosed tissue with putrefactive bacteria. The 
general condition and age of the patient play an important part in arriving 
at correct prognostic conclusions. Patients debilitated from antecedent 
acute or chronic disease are in greater peril of life than robust, healthy per- 
sons whose circulation and tissue-resistance have not been impaired. In- 
fants and the aged succumb to gangrene more readily than young adults 
and persons in middle life, although the gangrene may have resulted from 
the same causes, reached the same extent, and involved the same parts. 
Gangrene of some important organ, as the lungs or intestines, is more dan- 
gerous to life than peripheral gangrene. The coexistence of complications, 
such as diabetes, Bright's disease, tuberculosis, valvular disease of the heart, 
and cirrhosis of the liver will influence the prognosis correspondingly. 

Treatment. — The prophylactic treatment includes such measures, me- 
dicinal, dietetic, and otherwise, as are calculated to improve the blood-sup- 
ply of the part threatened with gangrene, and, if this has occurred or is 
inevitable, to prevent putrefaction of the dead tissues. In threatened gan- 
grene from obstruction of the main artery of a limb, the establishment of 
collateral circulation must be aided by placing the limb in a horizontal or 
slightly-elevated position, and by the external application of dry heat. In 
the aged suffering from premonitory peripheral symptoms of gangrene, its 
actual occurrence can often be postponed by massage, rubbing the limb from 
the toes toward the body for ten or fifteen minutes twice daily, and by the 
avoidance of all causes which would bring about stasis in the enfeebled 
blood-vessels. The minutest lesions of the skin — as abrasions, corns, bun- 
ions, ulcers, etc. — should receive careful attention in all persons the sub- 
jects of a feeble circulation, as they frequently are the starting-points of 
gangrenous inflammation. Diabetic persons are exceedingly liable to be at- 
tacked with gangrene after the slightest operation or the most insignificant 
injury, and on this account it is advisable to examine the urine before un- 
dertaking an operation on persons presenting the faintest evidence of this 
disease. As most forms of gangrene are of mycotic origin, all infection-atria 
should be protected against infection from without by thorough aseptic 
precautions. The prevention of decubitus has already been referred to, and 



216 PRINCIPLES OF SURGERY. 

here will be only mentioned the necessity of securing for the necrosed tis- 
sues an aseptic condition by rigid cleanliness and antiseptic measures in 
cases where the necrosis has occurred, or where it cannot be prevented. In 
moist gangrene the prevention of putrefaction is a most difficult task. Where 
gangrene of this type has occurred or is anticipated, the whole surface far 
beyond the area involved or threatened should be rendered aseptic in the 
same manner as in the preparation for an operation, and the parts protected 
as far as possible against invasion with putrefactive bacteria by an absorbent 
antiseptic dressing. A few layers of gauze and a thick compress of salicylated 
cotton answer an excellent purpose in meeting this indication. If gangrene 
With putrefaction has occurred, the etiological indications for local treat- 
ment are best met by multiple incisions through the necrosed tissues and 
undermined skin and the application of a compress wrung out of a 1-per- 
cent, solution of acetate of aluminum. If the fcetor is intense, Labarraque's 
solution of chlorinated soda, properly diluted, answers an admirable purpose. 
In gangrene with partial separation of the slough and considerable under- 
mining, permanent irrigation with either of these preparations answers the 
best purpose. All patients suffering from gangrene are debilitated from 
antecedent or concomitant causes, and consequently are badly affected by 
any form of the so-called antiphlogistic or sedative treatment. Fever is 
always the result of the entrance of septic material, and should therefore not 
be treated by antipyretics, but by local measures directed toward the pri- 
mary cause. Quinine in sedative doses does more harm than good. Vera- 
trum viride, tartar emetic, and the innumerable chemical substances which 
have recently been so much lauded as antif ever remedies should never be pre- 
scribed in the treatment of fever attending necrosis. The patient's strength 
must be supported from the beginning by a liberal diet and the use of stim- 
ulants. If the heart's action is feeble, digitalis can be given with benefit. 
Quinine in tonic doses is indicated. Anorexia not dependent on high fever 
calls for some one or a combination of bitter tonics. The part affected must 
be placed at rest and in a position most favorable for the passage of the 
blood through the capillaries. 

The question of removal of gangrenous tissue and the amputation of a 
gangrenous limb should receive thoughtful, conscientious consideration be- 
fore an operation is undertaken. The favorable results which have followed 
the operative removal of a gangrenous part after the line of demarcation had 
formed, and the great mortality of operations undertaken without such a 
positive indication, have led many good surgeons to advise postponement 
of all operative procedure until nature has indicated the site of operation. 
This conservative rule, however, is incompatible with the teachings' of mod- 
ern surgery. We know that death in cases of rapidly-spreading gangrene 
is caused by septic intoxication. We also know that the cause of the septic 



PATHOLOGICAL AND CLINICAL VARIETIES OF NECROSIS. 217 

intoxication inhabits the dead tissue, and we are also aware that the exten- 
sion of the immediate cause of gangrene (vessel-obstruction), ascending 
thrombosis in the arteries, and ascending thrombophlebitis in the veins pro- 
ceed from the gangrenous part. In view of these facts, the delay of operative 
measures in the treatment of gangrene until the line of demarcation has been 
established would be to wait for something which, in the most urgent cases, 
never occurs. In the absence of symptoms indicating danger from septi- 
csemia it is not only advisable, but absolutely necessary, to postpone the oper- 
ative removal of the gangrenous part until nature locates the site for the 
operation by the formation of the line of demarcation. In aseptic dry gan- 
grene involving parts where no formal operation is necessary to secure a 
favorable healing, later spontaneous elimination should be waited for, and 
after separation of the necrosed tissue the granulating surface is treated in 
the usual manner. In moist gangrene the dead tissue is removed as soon as 
partial separation has taken place by dividing with scissors the more re- 
sistant structures, as fascia and tendons, after which the resulting wound is 
treated upon antiseptic principles. In gangrene of the extremities amputa- 
tion can be done safely, and with good prospects of success, as soon as the 
line of demarcation has formed. In such cases it is necessary to remove as 
little as possible of the healthy tissue by carrying the incisions in such a man- 
ner as to leave flaps composed of healthy tissue simply long enough to cover 
the bone. No typical operation should be adopted, as the flaps must be made 
not in conformity with any text-book rules, but the condition of the limb. 
If the patient is febrile, and the character of the fever indicates as its origin 
the gangrenous part, delay, to say the least, is attended by increased danger 
of extension of the gangrene, and death from septicaemia. Such cases fare 
best at the hands of prudent, but courageous, surgeons. Procrastination in 
such cases is a sign of timidity or ignorance. What is to be done must be 
done at once. The patient and friends must be made acquainted with the 
dangers incident to delay, and the only prospect of recovery by early amputa- 
tion. Consultation with one or more of the neighboring physicians is an ab- 
solute necessity in such cases. Fortified by a fair understanding with the 
patient and his friends, supported by the advice and counsel of one or more 
of his colleagues, no surgeon need fear to follow the dictates of his conscience, 
even in the most unpromising cases. The distinguished Hueter related sev- 
eral cases where early amputation saved the lives of patients who were in 
stupor from the effects of septic intoxication to such an extent that an anaes- 
thetic was unnecessary. Early amputation should be urged and done in all 
cases where life is placed in jeopardy from absorption of septic material from 
the gangrenous part. The results after amputation under such circum- 
stances will always remain uncertain, because in many instances fatal general 
infection occurs soon after the development of the first general symptoms, 

14a 



218 PRINCIPLES OF SURGERY. 

and the local infection frequently extends to the site of operation, rendering 
a recurrence of gangrene in the stump a great probability. Amputation 
should be done, as near as possible, through healthy tissue. Much good 
judgment is necessary to determine this location. It is safe to maintain that, 
the more acute the attack, the more distant should the amputation be made 
from the apparent boundary-line of the gangrene. In gangrene from ob- 
struction of a large blood-vessel and in gangrene attended by ascending 
thrombophlebitis, arterial thrombosis, or both of these conditions, the line 
of amputation should invariably fall through a point where the vessels are 
patent; otherwise, a recurrence of the disease is almost sure to take place. 
The concensus of opinion of modern surgeons is in favor of high amputation 
for diabetic gangrene; that is, in gangrene of the foot, amputation, as a rule, 
should be made above the knee-joint. Before the amputation is made the 
part to be removed should be enveloped in towels wrung out in an antiseptic 
solution for the purpose of preventing contamination of the wound with 
septic material from the dead tissue. It is almost needless to mention that 
Esmarch's elastic bandage should never be used, as by its application septic 
material might be forced into the circulation. The limb should be rendered 
as nearly bloodless as possible by holding it for a few minutes in a perpen- 
dicular position, when an elastic constrictor is applied some distance above 
the point selected for the amputation. In septic patients the parenchyma- 
tous oozing sometimes is difficult to control, but is managed most success- 
fully by keeping the limb in the elevated position,, and by making surface- 
pressure with a large, flat sponge or gauze compress wrung out in hot water. 
As most of these patients are prostrated from the effects of the disease, they 
are liable to surfer from shock, and measures should be resorted to to pre- 
vent this complication, or, at least, diminish its severity. For this purpose 
a subcutaneous injection of 1 / 100 to 2 / 100 grain of atropia with 1 / 6 grain of 
morphia or 1 / 20 grain of strychnia is administered before the anaesthetic is 
given. Two ounces of whisky or the same amount of brandy should be 
given at the same time by the stomach, or, preferably, per rectum. Ether 
is preferable to chloroform in these cases as an anaesthetic. After the oper- 
ation the most careful after-treatment is required to meet possible emer- 
gencies. Shock is treated by alcoholic stimulants, camphorated oil, musk, 
strychnia, and coffee, and in grave cases by subcutaneous or intravenous in- 
fusion of normal salt solution. If the stomach is irritable, brandy, whisky, 
or coffee is administered by the rectum. Camphorated oil or musk is given 
hypodermically every half-hour until the patient reacts. External heat is 
useful in relieving congestions of internal organs and in stimulating the 
action of the heart. Amputation wounds made through tissues that are 
not positively known to be aseptic should always be drained; this is the 
more necessary if the soft tissues are cedematous. Should the tissues at 



PATHOLOGICAL AM) CLINICAL VARIETIES OF NECROSIS. 219 

the seal of amputation not preseni a satisfactory appearance, it is advisable 
to go up higher, more especially if the vessels are obstructed by a throm- 
bus. The fate of the patient is decided within a few days after the am- 
putation. The most favorable symptom is a reduction of the tempera- 
ture to normal within a few hours after the operation, which will be the 
case if the fever has been caused by a septic intoxication. With the re- 
moval of the tissues which furnished the toxic substances and the elimi- 
nation of these through the secretory organs, the septic symptoms sub- 
side; and if the patient have enough strength left to carry him over the 
immediate effects of the operation, the prospects of recovery are good. 
If the patient is the subject of a progressive sepsis, the amputation, in 
all probability, will prove powerless as a life-saving measure, as the mi- 
crobes which have reached the circulation reproduce themselves with great 
rapidit}% and death from this cause results within a few hours to several 
days. Prompt improvement soon after the operation, with recurrence of 
febrile symptoms in a few days, indicates the occurrence of gangrene in the 
stump. Such symptoms demand a change of dressing. If gangrene is pres- 
ent all sutures are removed and a thorough local disinfection practiced, after 
which the stump should be treated by constant antiseptic irrigation. Ke- 
amputation at this time would, in all probability, prove fatal, and reliance 
on local disinfection, combined with the use of stimulants and tonics, is 
advised with a feeble hope that these measures may become the means of 
limiting the extension of the disease and of supporting the heart's action 
until the line of demarcation is established, when the surgeon's services 
are again required to assist Nature's efforts in the elimination of the dead 
tissues. In noma and hospital gangrene the infected tissues are removed 
with the sharp spoon, and after thorough antiseptic irrigation the actual 
cautery is applied, and the further management of the wound is the same 
as in case of infected wounds from other causes. Chlorinated water and 
a solution of bromine are excellent preparations after the primary disin- 
fection and cauterization in the treatment of these diseases. 



CHAPTER IX. 

Suppuration, 
bacteriological causes and histogenesis of suppuration. 

Suppuration is the most frequent termination of acute inflammation. 
Inflammation terminating in the formation of pus is called suppurative, 
both on account of its etiology and the nature of the inflammatory product. 
Suppuration is the process by which the morphological elements of the 
inflammatory product, the leucocytes, and embryonal cells are converted 
into pus-corpuscles. Suppurative inflammation is caused by the action 
upon the tissues of specific microorganisms, the pus-microbes, and the 
transformation of leucocytes and embryonal cells into pus-corpuscles is 
accomplished by the same cause. The brilliant results which have been 
obtained by the antiseptic treatment of wounds made it exceedingly prob- 
able that all wound-infective diseases are caused by living microorganisms. 
The probability was increased when Koch, in 1879, showed the direct con- 
nection existing between certain traumatic infective diseases in animals 
and the never-absent definite microorganisms. It requires no longer any 
arguments to show, at this time, that all inflammatory wound complica- 
tions, among them suppuration, are, without exception, caused by the in- 
troduction into the tissues of specific pathogenic microbes. Etiologically, 
most of the purulent processes constitute more of a unity than was for- 
merly believed, and the clinical varieties are mostly determined by the 
intensity of the infection, the manner of localization, and the degree of 
resistance possessed by the tissues. The most conclusive evidence of the 
correctness of this assertion is furnished by the fact that the same strepto- 
coccus which produces a simple abscess is likewise the most frequent cause 
of progressive gangrene, and of that most grave form of suppuration: 
pyaemia. 

I. HISTORY OF MICROBIC ORIGIN OF SUPPURATION. 

As in the case of nearly all infective diseases, years before the specific 
pus-microbes were discovered living organisms were found in pus and de- 
scribed, and were believed to be the essential cause of suppuration. More 
than thirty years ago Klebs discovered, in the tubuli uriniferi in cases 
of pyelonephritis following suppurative cystitis, between the pus-cells, 
small, round cocci, which he believed produced the infection. In 1872 
the same author published the result of his researches, during the Franco- 
Prussian War, on septic-wound diseases. In this work he again referred 

(220) 



HISTORY OF HICROBIC ORIGIN OF SUPPURATION. 221 

to the microorganisms which he had previously described, and showed 
that they existed in the tissues and organs — the seat of suppurative in- 
flammation — before pus had formed. He also showed how these microor- 
ganisms enter the circulation and become the direct cause of patho- 
logical conditions in distant organs. Even at that time he placed great 
stress on the fact that, as long as the cocci remained only in the tissues 
at the point of infection, they produce only local inflammation or necrosis, 
but as soon as they enter the circulation fever and other symptoms of 
general septic infection follow. 

Ogston, the discoverer of pus-microbes, published the results of his 
observations and researches in 1881. This patient investigator examined 
the pus of 69 abscesses for microorganisms, and found in 17 of them a 
chain coccus (streptococcus), in 31 cocci which arranged themselves in 
groups which resemble a bunch of grapes (staphylococcus), and in 16 both 
of these forms were present. In cold abscess he was unable to find either 
of these microorganisms. He also ascertained that these two forms of 
microbes differed in their manner of diffusion in and action on the tissues, 
as the streptococcus, following the lymph-channels and connective-tissue 
spaces, was seen to be the cause of diffuse suppurative processes, while the 
staphylococcus was found by him only in abscesses which were circum- 
scribed. 

Eosenbach took up the work where Ogston left -it, and, as the fruit 
of a number of years of patient study and research, published his classical 
work in 1884 ("Microorganismen bei den Tvundinfections Krankheiten des 
Menschen," Tviesbaden, 1884). This work must serve as a basis for all 
future research on suppurative inflammation. Eosenbach availed himself 
of the advantages offered by an improved technique in bacteriological 
research, cultivated the different pus-microbes upon solid nutrient media, 
and pointed out the difference in the macroscopical appearances of the 
cultures of the different kinds of pus-microbes, which enabled him to dif- 
ferentiate between them by the naked-eye appearances of the cultures 
upon the different nutrient substances. He discovered the staphylococcus 
pyogenes aureus, the micrococcus pyogenes tenuis, and three kinds of 
bacillus saprogenes. 

Passet should be mertioned next in the long list of distinguished 
names of original investigators who have made the bacteriology of sup- 
puration a special study. He discovered and described the staphylococcus 
citreus and the staphylococcus cereus albus and flavus, and from a peri- 
rectal abscess he cultivated the bacillus pyogenes fcetidus. The strepto- 
coccus which he found he maintained was different from the one described 
by Eosenbach, as it resembled more closely the streptococcus of erysipelas, 
but this claim has not been substantiated by subsequent investigations. 



222 PRINCIPLES OF SURGERY. 

The bacillus pyocyaneus was described by Gessard and Charrin. The 
gonococcus, the specific microbe of gonorrhoea, was discovered by Neisser, 
in 1879. In our own country the microorganisms of pus have been studied 
by such men as Sternberg, Osier, Councilman, Welch, Ernst, and Park. 

II. INDIRECT CAUSES OF SUPPURATION. 

Inflammation produces in the tissues conditions which must be re- 
garded as indirect causes of suppuration. These conditions favor the sup- 
purative process by bringing the histological elements of the inflammatory 
product in a position or relation to the blood-vessels which impairs or sus- 
pends their nutrient supply. In acute inflammation the connective-tissue 
spaces become crowded, in a short time, with the corpuscular elements of 
the blood, which, by their presence in such great number, cause dilata- 
tion of these spaces and pressure upon the adjacent capillary vessels, 
which often result in complete stasis and consequently arrest of blood- 
supply. In consequence of suspended nutrition arising from vascular ob- 
struction, the leucocytes undergo coagulation-necrosis and lose their power 
of resistance to the action of pathogenic microorganisms. If inflammation 
attack the fixed tissue-cells with an intensity short of producing necrosis, 
the cells proliferate and the embryonal cells thus produced constitute an- 
other source of histological elements of the inflammatory product. If the 
cells are produced in excess of the capacity of the inflamed part to supply 
them with new blood-vessels, the local anaemia thus created places them 
in the same unfavorable condition as the leucocytes in the crowded con- 
nective-tissue spaces, and they are exposed to the same risk of death from 
malnutrition. If, as the result of rapid tissue-proliferation and local 
ischaemia, the embryonal cell become completely detached from the matrix 
which produced it, it is placed in the worst condition, so far as its vitality 
and vegetative capacities are concerned, and it readily succumbs to the 
deleterious action of the pus-microbes. It can be set clown as a rule that 
all conditions, local or general, which impair cell-nutrition favor the sup- 
purative process. Suppuration in inflammatory foci is always observed 
first where cell-nutrition is most impaired, hence in the primary inflam- 
matory product among the leucocytes most distant from capillary vessels, 
and among embryonal cells that have become isolated or occupy a place 
most remote from the vascular supply. 

III. DIRECT CAUSES OF SUPPURATION. 

Clinical suppuration is caused by the action of pus-microbes or their 
toxins on the leucocytes and embryonal cells, by which these cells, the 
morphological elements of the inflammatory product, are converted into 



DIRECT CAUSES OF SUPPURATION. 223 

pus-corpuscles. A number of investigators maintain that suppuration can 
be produced artificially in animals by injecting into the tissues certain 

Chemical Pyogenic Substances. — The substances which have been 
found to possess the property of exciting suppurative inflammation are 
metallic mercury, turpentine, and croton-oil. Councilman introduced 
turpentine and croton-oil in aseptic glass capsules into the subcutaneous 
connective tissue of animals under strict aseptic precautions, and, after 
the wound had healed and the capsules had become encysted, ruptured 
them subcutaneously. He found that both of these substances caused a 
circumscribed suppuration. Uskoff claimed that a considerable quantity 
of indifferent substances, such as milk, olive-oil, etc., if injected spon- 
taneously in animals, either at once or by repeating the injection from 
time to time, caused suppuration, and that turpentine administered in 
the same manner always acted as a pyogenic agent. Orthmann, nnder 
Kosenbach/s supervision, repeated TlskofPs experiments, and, by resorting 
to more strict aseptic precautions, conld not verify the correctness of 
his conclnsions in reference to the pns-prodncing properties of indifferent 
substances. His experiments with croton-oil, turpentine, and metallic 
mercury always resulted in inflammation and suppuration. Grawitz and 
de Bary ascertained that croton-oil, when injected in small quantities into 
the subcutaneous tissues of rabbits, caused a serous transudation or a 
fibrinous exudation, while larger doses acted as a caustic, and were only 
occasionally followed by suppuration. If they injected a mixture of pus- 
microbes and croton-oil it always was followed by the formation of pus. 
They maintained that certain chemical substances, used in a definite de- 
gree of concentration, injected into the subcutaneous tissues of animals, 
prepared the tissues for the growth of the pus-microbes. From a later 
series of experiments Grawitz became more firmly convinced that aseptic 
turpentine, used in sufficient quantities, always causes a suppurative in- 
flammation in the connective tissue. Inoculations of different nutrient 
media with pus produced by turpentine showed that it contained no pus- 
microbes. He also determined that such chemical pus had a destructive 
effect on pus-microbes. This action of sterile pus he attributes not to 
the presence of toxins, but to the action of its albuminous constituents. 
His experiments also lead to the important observation that when gelatin 
cultures are oversaturated with albumin, or peptone, pus-microbes cease to 
multiply. A number of years ago Kosenbach made a series of experi- 
ments which has convinced him that the chemical pyogenic substances 
which have been mentioned, when injected into the tissues of animals, 
cause suppuration independently of the presence of pus-microbes. Eeichel 
has made numerous experiments on animals by injecting gradually- 
increasing doses of pus-microbes or their toxins into the peritoneal cavity, 



224 PRINCIPLES OF SURGERY. 

and has proved that a certain degree of immunity is procured, by this 
treatment, to infection with large doses of pus-microbes, which, in other 
animals not thus treated, produced fatal suppurative peritonitis. He 
maintains that suppuration caused by microbes and their chemical 
products is in so far different that the former may produce metastases, 
while the suppuration caused exclusively by toxins always remains local. 
Buchner has recently demonstrated, by experiments, that sterilized cult- 
ures of a long list of bacteria — seventeen species tested — give rise to sup- 
puration when injected into the subcutaneous tissues. The same author 
has also shown that the pyogenic action of these cultures is due to the 
dead microbes, as injections of the clear filtrate yielded only negative re- 
sults. The toxalbumin of staphylococcus aureus killed rabbits and guinea- 
pigs within a few days, and in some cases at the end of twenty-four hours. 
The post-mortem appearances were necrosis or purulent infiltration at the 
point of injection, with external changes which were characteristic of 
inflammation. 

Among those who, from their own experimental work, have come to 
diametrically opposite conclusions can be mentioned Scheuerlen, Euiys, 
Nathan, and Biondi. 

If we consider for a moment how very difficult it is, in experimenting 
on animals with indifferent substances and chemical irritants, to procure 
for the seat of injection a perfectly aseptic condition, it is not at all diffi- 
cult to conceive that opinions still differ in regard to the immediate and 
essential cause of suppuration. Taking it for granted that certain chem- 
ical pyogenic substances, when injected in sufficient quantities into the 
tissues of animals, have the power to produce suppuration, inflammation 
and suppuration produced in such a manner do not represent clinically 
suppurative affections. Neither the inflammation nor the suppuration 
following such experiments are progressive in their character. The chem- 
ical substances produce inflammation over an area which corresponds with 
the extent of its diffusion, and the cellular elements of the inflammatory 
product are converted into pus-corpuscles by the destructive action of the 
substance on their protoplasm. The whole course of the artificial affec- 
tion remains aseptic throughout, and the pus which is produced is aseptic 
and sterile, — not clinical, but chemical, pus. 

In suppuration, as we see it at the bedside, the direct cause which 
produced it multiplies in the tissues; hence its tendency to become pro- 
gressive, and from the pus which is produced the immediate and essential 
cause — the pus-microbes — can be cultivated. Practically, in man, the oc- 
currence of suppuration from the action of pyogenic chemical substances 
would be possible only on the surface of the body. 

Pus-microbes. — That the pus-microbes are the immediate and essential 



DIKECT CAUSES OF SUPPURATION, 



225 



cause of suppurative inflammation and pus-formation has been well estab- 
lished by clinical observation and experimentation. Clinical experience dur- 
ing the last thirty years has shown beyond all doubt that suppuration in 
wounds can be prevented by measures which are calculated to remove, de- 
stroy, and exclude pathogenic microorganisms from without. 

Eosenbach discovered that, in. dogs and rabbits, a small quantity of a 
pure culture of the staphylococcus pyogenes aureus injected under the 
skin produced a most violent suppurative inflammation; cultures of the 
staphylococcus pyogenes albus had the same effect. Cultures of the strep- 
tococcus pyogenes produced only slight inflammation in rabbits while they 
proved very fatal in mice. 

Passet procured a pure culture of the staphylococcus pyogenes aureus, 
about the size of a pea, which had been grown upon potato, and mixed it 




Fig. 85. — Vertical Section through a Subcutaneous Abscess Caused by Inoculation 
with Staphylococci in the Rabbit, Forty-eight Hours after Infection; Margin toward the 
Normal Tissue. (Bailing arten.) 



with 1 cubic centimetre of distilled water. Of this mixture he injected 
under the skin of a mouse 0.1 cubic centimetre; the animal recovered. An- 
other mouse was treated in the same manner, but 0.4 cubic centimetre of a 
liquefled-gelatin culture was used, and this animal died in eighteen hours. 
Cocci were found in the blood. In rabbits and dogs a subcutaneous injec- 
tion of 1 cubic centimetre of liquid-gelatin culture of the aureus usually 
produced an abscess at the point of inoculation. If the dose was increased 
to 5 cubic centimetres of the same culture the animals died in from 
eighteen to twenty hours. At the same time a local inflammation was 
found at the site of inoculation. In all of the fatal cases the pus-microbe 
was found in the blood. Of the culture of the streptococcus pyogenes it 
was found necessary to inject a considerable quantity in order to produce 
suppuration. Liquefied-gelatin cultures of the staphylococcus pyogenes 



226 PRINCIPLES OF SURGERY. 

aureus and albus, in doses of 1 cubic centimetre, injected into the abdom- 
inal cavity of rabbits, were well tolerated, and death was produced only 
when the dose was increased to from 4 to 6 cubic centimetres. Injection 
of cultures of the streptococcus pyogenes into the peritoneal cavity was 
even better tolerated, and usually had to be repeated several times before 
the animal died of septic peritonitis. A needle dipped into a culture of 
pus-microbes he could insert into joints without causing suppuration; but 
the injection of from 0.3 to 0.5 cubic centimetre of a mixture of pus- 
microbes suspended in distilled water, into the hip-joint of rabbits, was 
followed by suppurative arthritis, rupture of the capsule, and diffuse par- 
aarticular phlegmonous inflammation and suppuration, and often death of 
the animal. Injection of 1 or 2 drops of a liquefied-gelatin culture of the 
staphylococcus pyogenes aureus, or albus, into a vein of a rabbit did not 
produce any serious disturbance; but, if the dose was increased to from 
0.5 to 1 cubic centimetre, it, as a rule, caused a fatal disease. In such 
cases multiple suppurating foci were found in the kidney, liver, spleen, 
and lungs, with pleuritis and peritoneal effusion, pericarditis, and myo- 
carditis; also serous and purulent effusions into joints and muscular 
abscesses. 

The effect of inoculation with pus-microbes in man is the same as in 
animals. Garre made a superficial abrasion on one of his fingers, and ap- 
plied a pure culture of the staphylococcus pyogenes aureus; the only symp- 
tom observed was a slight redness eighteen to twenty-four hours after the 
inoculation. He then made three small incisions, and inoculated himself 
with a larger quantity of the culture, which was followed by superficial 
suppuration. 

Fehleisen repeated precisely similar experiments upon himself with 
cultures of different kinds of pus-microbes, and, if he succeeded in causing 
suppuration, this was always very slight. He also found that minute doses, 
administered subcutaneously, were harmless; while larger doses, sus- 
pended in water, almost without exception caused abscesses, and, in ani- 
mals, very large doses produced death from sepsis before suppuration could 
take place. Bockhardt introduced a trace of a mixed culture of staphylo- 
coccus aureus and albus into the cutis of his left forefinger; after forty- 
eight hours a small abscess had formed, which was opened, and in the pus 
the same microbes were demonstrated. Bumm injected a pure culture of 
the yellow staphylococcus into the subcutaneous tissue of his own arm, 
and into the arms of two other persons. In each instance an abscess de- 
veloped, which varied from the size of a pigeon's egg to that of a man's 
fist, according to the time which elapsed before they were opened. In the 
pus of these abscesses the same pus-microbe which had been injected was 
found. The above observations are conclusive in showing that pus- 



DIBBCT CAUSES OF SUPPURATION. 221 

microbes can be cultivated from the pus of every acute abscess, and that, 
in man and animals, the injection of a sufficient quantity of a pure culture 
into the tissues is followed by suppuration; and thus far positive proof 
lias been furnished of the direct etiological relationship which exists be- 
tween pus-microbes and suppuration. Einne published an account of his 
experiments, and his results are somewhat in conflict with the authorities 
quoted above. He frequently failed to produce suppurative inflammation, 
even when he injected a large quantity of a pure culture, and by repeating 
the injection from time to time. He is of the opinion that, when the 
absorptive capacity of the tissues is not diminished, the pus-microbes are 
removed too rapidly to produce their pathogenic effect. The effect of 
inoculation with pus-microbes will, of course, always vary, according to the 
quantity of the microbes and the local and general susceptibility of the 
animal experimented on. Watson Cheyne has shown most conclusively 
that the number of bacteria introduced greatly modifies not only the in- 
tensity of the symptoms, but also the character of the disease. His experi- 
Lents were made with cultivations of Hauser's proteus vulgaris. He esti- 
mated that 1 / 10 cubic centimetre of an undiluted culture of this microbe 
contains 225,000,000 bacteria, and when this quantity was injected into 
the muscular tissue of a rabbit it produced speedy death. A quantity of 
the same culture corresponding with a / 40 cubic centimetre, administered 
in the same manner, caused an extensive abscess at the point of injection, 
and death of the animal in six or eight weeks. Doses of less than x / 500 
cubic centimetre produced no effect, — in fact, doses of less than 1 / 12 to 
V120 cubic centimetre, or, in other words, fewer than about 18,000,000 bac- 
teria, seldom caused any positive result. The same author found that in 
the case of the staphylococcus pyogenes aureus it was necessary to inject 
something like 1,000,000,000 cocci into the muscles of rabbits, in order 
to cause a rapidly-fatal result, while 250,000,000 produced a small abscess. 
In the case of the tetanus bacillus, death did not occur in rabbits when 
fewer than 1000 bacilli were introduced. He believes, as does Einne, that 
the action of the preformed toxins on the tissues modifies the result. It 
is, therefore, probable that, in the experiments in which injection of pus- 
microbes did not produce suppuration, an insufficient number of active 
microbes were used, and that where indifferent substances and chemical 
irritants caused suppuration the implanted or injected material was con- 
taminated, or that infection at the point of injection occurred through the 
wound, or subsequently through the circulation. The latter method of 
infection should always be borne in mind in cases where the presence of 
an aseptic substance in the tissues has apparently been the cause of sup- 
puration. The tissues altered by the action of chemical irritants consti- 
tute a foreign substance, which may determine localization of microbes 



£38 PRINCIPLES OF SURGERY. 

floating in the circulation, while, at the same time, the chemical altera- 
tions which they have caused in the tissues have prepared a favorable soil 
for their reproduction. Of late a number of pathologists have gone one 
step further, and maintain that pus-microbes are not the direct cause of 
suppuration, but that their presence is essential for the production of 
toxins, to which they attribute pyogenic properties. If certain pyogenic, 
aseptic, chemical substances can convert living cellular elements into pus- 
corpuscles, as has been asserted upon good authorit}-, we should naturally 
expect that chemical substances produced by pus-microbes in inflamed 
tissue might possess the same pathogenic property, and we will briefly con- 
sider what is known in reference to 

Toxins of Pus-microbes as a Cause of Suppuration. — Grawitz and 
cle Bary, after detailing the results of their experiments with injections 
of chemical irritants in their investigations on pus-formation, give an ac- 
count of their experiments with the toxins of pus-microbes. They main- 
tain that these toxins, like chemical irritants, prepare the tissues for the 
growth and reproduction of pus-microbes. The action of these substances 
can be studied by injecting sterilized cultures of pus-microbes, in which 
the only active agents could be the preformed toxins. These observers 
injected 4 cubic centimetres of a sterilized culture of the staphylococcus 
pyogenes aureus under the skin of a dog, with the effect of causing sup- 
puration. The pus was examined for microbes, but none were found. 
They assert that the presence of oxygen is of the greatest importance in 
the production of toxins. Grawitz experimented also with a pure prepara- 
tion of cadaverin, prepared by Brieger from bacteria. Cadaverin is a 
colorless fluid, the chemical formula of which is identical with penta- 
methylendiamin; a 2 1 / 2 -per-cent. solution of this substance destroyed the 
staphylococcus pyogenes aureus in an hour, and a small quantity added to 
a culture of pus-microbes arrested further growth. A solution absolutely 
free from microbes, injected under the skin of animals, according to 
strength and quantity used, produced cauterization or inflammation, ter- 
minating in suppuration or inflammatory oedema, followed by resolution 
and absorption. The pus produced by cadaverin contained no bacteria as 
long as the skin remained intact. The injection of a mixture of a solution 
of cadaverin and pus-microbes was always followed by a progressive phleg- 
monous inflammation. Scheuerlen was the first to study the local action 
of toxins on the tissues. He introduced into the subcutaneous connective 
tissue of rabbits aseptic glass capsules containing sterilized infusion of 
meat. The wounds healed by primary union. As soon as the capsules had 
become encysted, he broke off both ends of the capsule, so as to saturate 
the tissues in its immediate vicinity with the fluid it contained. Three 
to six weeks after implantation of the capsule an incision was made down 



DIRECT C w SES OP SUPPURATION. ■- ; "- ) '.» 

to it. and the pans submitted to a thorough examination. The ends of 
the capsule were always found to contain a few drops of thin, yellow pus, 
which, under the microscope, showed all the characteristic appearances of 
that fluid. No inflammation of the surrounding tissues. Cultivation ex- 
periments with the pus yielded negative results. It is evident that sup- 
puration in these instances was caused by the action of the preformed 
toxins on the leucocytes and embryonal cells, and that its extension did 
not occur because the cause did not multiply in the tissues. In about 
twenty experiments the pus was found only inside of the capsule. Weigert 
has repeatedly shown that the difference between a purulent and fibrinous 
exudation can be readily demonstrated, as the former does not coagulate, 
although white corpuscles and plasma may be present. 

Klemperer believes that this difference is due to previous destruction 
of fibrinogen in the pus by the pus-microbes. The putrid-meat infusion 
used by Scheuerlen caused limited suppuration, and on that account it 
must also have possessed the property to prevent coagulation. To prove 
this he made the following experiment: The abdomen of a rabbit was 
opened while the animal was under the influence of chloroform, and blood 
was drawn directly from the aorta into a glass tube containing putrid ex- 
tract of meat. As the fluids gradually became mixed the blood assumed a 
brownish-red color; coagulation did not occur for hours and days, while 
in the control exj^eriments, with solution of salt, the blood coagulated 
firmly after the lapse of a few minutes. He next made thirty cultures of 
the staphylococcus pyogenes aureus upon agar-agar gelatin, and the same 
number of cultures of the albus, and after completion of their growth, 
fourteen days later, he sterilized them with boiling water, and, after shak- 
ing the fluid, removed the cultures and boiled them for a few minutes, and 
finally filtered them; he thus obtained about 150 cubic centimetres of a 
light-yellow fluid. This was reduced to 8 cubic centimetres by boiling; 
before using, the fluid was again filtered. The filtrate was put in capsules, 
and after sealing their ends hermetically they were inserted into the sub- 
cutaneous connective tissue of animals with the same care as in the preced- 
ing experiments. The suppuration which followed the breaking of the 
glass capsule in these cases was again found to be limited to the space 
within the capsule, being caused by action of the preformed toxins on leu- 
cocytes and embryonal cells, which found their way into the interior of 
the glass capsule. 

The cadaverin and putrescin, two ptomaines prepared by Brieger, 
were next experimented with in the same manner. In preventing coagula- 
tion the results were even more striking than with the former substances. 
These experiments leave no doubt that toxins derived from pyogenic bac- 
teria produce a chemical action on leucocytes and embryonal cells by 



230 PRINCIPLES OF SURGERY. 

which they are converted into pus-corpuscles. The suppuration thus pro- 
duced, however, never extends beyond the tissues which are brought in 
contact with them, and, therefore, always remain circumscribed. In this 
respect the results of the experiments just cited do not correspond with sup- 
puration as we observe it in practice, as here from the same causes, and ap- 
parently often under the same conditions, the process presents the greatest 
possible variations in reference to its intensity and extent. In one case the 
suppuration remains circumscribed, resulting in a furuncle; in others the 
regional infection is more extensive, and a diffuse, phlegmonous inflammation 
is the result; while in the third class the local infection leads to general sys- 
temic invasion, and the patient dies of sepsis or pycemia. The clinical form 
of suppuration is noted for the progressive character of the infection, 
which is due to the reproduction of pus-microbes in the tissues and the 
production of toxins proportionate in amount to the number of microbes 
present, and, perhaps, also modified, to a certain extent, by the character 
of the soil. Practically, the matter remains the same as before it was 
known that the toxins produced in the tissues by the pyogenic microor- 
ganisms could cause suppuration, as pus-microbes must be introduced 
into the organism, where they must also find an appropriate soil for their 
reproduction, before toxins can be produced in sufficient quantity to ac- 
count for the occurrence of the clinical forms of suppuration. To the 
practical surgeon it is immaterial to know whether the transformation 
of leucocytes and embryonal cells into pus-corpuscles is brought about by 
the direct action of pus-microbes or by the toxins which they produce in 
the tissues. 

Description and Specific Action of the Different Pus-microbes. — The 
microbes which, when present in sufficient number in the tissues, excite 
suppurative inflammation are called pyogenic or pus- microbes. Their 
effect on the cellular elements of the inflammatory product is a specific 
one, converting them into pus-corpuscles. Only such microbes will be 
described here which have been cultivated from pus, and the specific action 
of which has been demonstrated experimentally. 

1. Staphylococcus Pyogenes Aureus. — The yellow staphylococcus is 
the microbe most frequently present in acute abscesses. Under the micro- 
scope it cannot be distinguished from the staphylococcus pyogenes albus. 

It is easily cultivated upon gelatin, agar-agar, coagulated blood-serum, 
and potato. The culture liquefies gelatin. It grows best at a temperature 
approaching that of the blood, but can be cultivated at 30° C. It pep- 
tonizes albumen and coagulates milk. The culture grows in the track of 
the needle and upon the surface of the nutrient medium. The gold-yellow 
color of the culture appears only if the colony is exposed to atmospheric 
air. Cultures upon gelatin or agar-agar retain their virulence for a year 



DIRECT CAUSES OF SUPPURATION. 231 

or more. This coccus is met with frequently in acute circumscribed 
abscesses, osteomyelitis, pyaemia, and ulcerative endocarditis. 

2. Staphylococcus Pyogenes Albus. — This pus-microbe can be distin- 
guished from the yellow coccus only by the color of the culture, which is 
white. Both Passet and Klebs have observed in the white culture of this 
coccus small yellow dots, which, when isolated, lost their color. These 
authors, therefore, consider the yellow and white staphylococci as varieties 
of the same kind of pus-microbes. As other experimenters have not been 
able to verify these observations, we must take it for granted that the 
staphylococcus pyogenes albus differs from the aureus in that it possesses 
no power to produce the same yellow color which characterizes the culture 
of the latter. Its pathogenic properties, both in man and animals, are 
somewhat less than those of the aureus. Passet claims that the white 
coccus is more frequently found in the suppurative lesions in man than 
the yellow, while Kosenbach makes a contrary assertion. The latter 
author seldom found it alone in pus, but more frequently associated with 
the aureus. The cultures of both the yellow and white staphylococcus 



f i 

Fig. 86.— Microscopical Pictures of Staphylococcus. 1, culture twenty-four 
hours; 2, culture two months. (Rosenbach.) 

upon gelatin present an irregular surface, and the margins are dotted with 
minute globular projections. Both of these microbes liquefy gelatin, but 
agar-agar and coagulated blood-serum are not similarly affected. 

3. Staphylococcus Pyogenes Citreus. — Found by Passet in about 10 
per cent, of acute abscesses examined. Like the aureus and albus, it 
liquefies gelatin. Cocci singly, or in pairs, or zooglcea. If cultivated on 
nutrient gelatin, or agar-agar, a sulphur or lemon-yellow growth develops 
after twenty-four hours, which at that time resembles the aureus, but 
later does not change into a gold-yellow color. Like the aureus, pigmenta- 
tion only takes place if the culture is exposed to air. According to Passet, 
its virulence is somewhat less than that of the aureus and albus. This 
statement has been confirmed by Cheyne. When a culture of this pus- 
microbe is injected under the skin of mice, guinea-pigs, or rabbits, an 
abscess forms, from the pus of which a culture of the same lemon color 
can be obtained. 

4. Staphylococcus Cereus Albus. — This microbe was first discovered 
by Passet in the pus of a periosteal abscess of a finger, as well as in an 
abscess of the heel. A culture upon gelatin is distinguished from that of 



232 PRINCIPLES OF SURGERY. 

other pus-microbes upon the same nutrient medium by its forming a 
white, slightly-shining layer, like drops of white wax, with a somewhat 
thickened, irregular edge. The needle-stab develops into a grayish-white, 
granular thread. In plate cultures, on the first day, white points are ob- 
served, which spread themselves out on the surface to spots one-half a 
millimetre in diameter; when cultivated on blood-serum, a grayish-white, 
slightly-shining streak develops; and on potato the cocci form a layer 
which is similarly colored. This microbe is not pathogenic in rabbits. 

5. Staphylococcus Cereus Flavus. — Passet cultivated this microbe from 
the pus of a case of chronic periostitis of the tibia. If cultivated on 
gelatin, the growth, which is at first white, becomes of a citron-yellow 
color, resembling somewhat yellow wax, considerably darker than the 
culture of staphylococcus pyogenes citreus. Both varieties of staphylo- 
coccus cereus are very rarely met with in abscesses, and inoculation ex- 
periments with them have usually proved harmless. Baumgarten thinks 
it possible that in cases where they were found in abscesses they were not 
the cause of suppuration, but occurred as an accidental invasion after the 
pyogenic microbes had disappeared. 

6. Staphylococcus Flavescens. — This microbe was found in an abscess 
by Babes, and occupies an intermediate position between the staphylo- 
coccus pyogenes aureus and albus. On gelatin, the growth forms a color- 
less layer and causes liquefaction. It is fatal to mice, sometimes causing 
abscesses, and, in large doses, septicaemia. 

Welch described, a few years ago, a white staphylococcus which he 
found constantly upon and in the skin, which he called staphylococcus 
epidermidis albus. To this microbe he attributes the frequent occurrence 
of stitch-abscesses after operations during which the ordinary strict anti- 
septic precautions are carried out. 

7. Micrococcus Pyogenes Tenuis. — Eosenbach found this microorgan- 
ism in a large abscess which had given rise to no general symptoms. It 
is of rare occurrence. On agar-agar it forms an exceedingly delicate, 
almost invisible, white film. The individual cocci are irregular in shape 
and larger than the staphylococci. 

In all cases in which this microbe is the sole bacterial cause of sup- 
puration, the process appears to have been unattended by any very severe 
inflammatory symptoms and little or no general febrile disturbances. This 
microbe was not found by any one else but Eosenbach until February, 
1888, when Easkina isolated it from the pus and organs in a case of scar- 
latina complicated with pyaemia, which resulted fatally on the eighteenth 
day after the beginning of the primary disease. At the necropsy multiple 
miliary abscesses were found in the kidneys, at the junction of the cortex 
with the medullary portion. From the pus of these abscesses a pure cult- 



DIRECT CAUSES OF SUPPURATION, 



■j:i:5 





Fig. 87. — Common Forms of Pus-microbes. 1. Staphylococcus pyogenes aureus 
from a pyelonephritis in a man. (Gram's method.) 2. Bacillus pyocyaneus from a 
"green-pus" abscess. (Loeffler's methylene-blue.) 3. Streptococcus pyogenes from 
knee-joint of man dying of septicaemia. (Loeffler's methylene-blue.) 4. Bacillus coli 
commune and micrococcus tetragenus. Twenty-four-hour growth on glycerin-agar from 
peritoneum of a woman dying of peritonitis. (Loeffler's methylene-blue.) 



234 PRINCIPLES OF SURGERY. 

lire of the micrococcus was obtained. Inoculation experiments made on 
rabbits gave only negative results, even though the coccus was present 
in the blood twenty-four hours after inoculation; hence it is problematical 
as to its being a pyogenic microbe. Like the staphylococcus cereus, it 
probably belongs to the so-called met abiotic microbes of G-arre, occurring 
secondarily after suppuration has been established by genuine pyogenic 
microbes. 

8. Streptococcus Pyogenes. — Cocci, somewhat larger than staphylo- 
cocci, always divide transversely; so that they arrange themselves in the 
form of chains, which are usually more or less curved. 

The cocci also appear singly or as diplococci. Cultures grow very 
slowly on ordinary nutrient media at summer temperature, but with great 
rapidity at the temperature of the body. Cultivated in a streak on the 
surface of gelatin on a glass plate, this microbe forms at first whitish, 
somewhat transparent, rounded spots, of the size of small grains of sand. 
On agar-agar it grows most luxuriantly at a temperature of 35° to 37° C. 



r • % 
It _ x b 

Fig. 88. Fig. 89. 

Fig. 88. — Micrococcus Pyogenes Tenuis. Cultivated from pus in a 

Case of Empyema. (Rosenbach.) 
Fig. 89. — Streptococcus Pyogenes. (Rosenbach.) 

Even if the inoculation is made with the point of a needle in a continuous 
line, the culture appears in isolated, small points. In its further growth 
the culture is elevated in the centre, and presents a pale-brownish color, 
while the periphery is flattened, except at the extreme margin, which is 
again raised, and often with a spotted appearance. Still later the periph- 
ery develops successive layers or terraces, which were pointed out by 
Eosenbach as characteristic macroscopical features of the cultures of this 
microbe upon solid nutrient media. The growth is so slow that in two 
or three weeks the maximum width of the culture-streak is about 2 or 3 
millimetres. In a vacuum the streptococcus effects peptonization of albu- 
men and beef. Subcutaneous inoculation in mice yields negative results 
in about 80 per cent.; sometimes a slight suppuration follows at the seat 
of puncture; at times the animal dies without showing any particular 
pathological lesions, and no microorganisms can be found in any of the 
internal organs. In the subcutaneous tissue of rabbits in small quantities 
they cause hyperemia, redness, and slight swelling, which disappear in 



l>li;i:i T C w SES OF SUPPURATION. 235 

;he course ot two or three days; when Larger quantities arc used, some 
authors claim that they produce small circumscribed abscesses. In healthy 
rabbits intravenous injection of even a pure culture of the streptococcus 
causes no serious symptoms. If the animals are debilitated previously 
by injections of toxic substances, death is caused by rapid reproduction of 
the microbe in the tissues. If a pure culture is injected into a serous 
cavity, it causes, first, inflammation, and, later, effusion, which is again 
absorbed. In the pus from the human subject the streptococcus is found 
in about -10 to 60 per cent, of the specimens examined. This pus-microbe 
invades the tissues far in advance of suppuration. It is found most fre- 
quently in inflammations following the lymphatic channels. It is also 
found in grave affections, in progressive gangrene. In several cases of 
pyaemia cultures of the pus yielded a growth composed exclusively of the 
streptococcus. 

9. Bacillus Pyogenes Foetidus. — Passet found this microorganism in 
the pus of a perirectal abscess. This bacillus possesses slow motion, its 
ends are rounded, and in cultures appears usually in pairs. 



*m?: * s. g, 2 

Fig. 90. Fig. 91. 

Fig. 90.— Bacillus Pyogenes Fcetidus. X 790. (Fluegge.) 
Fig. 91.— Bacillus Pyocyaneus. X 700. {Fluegge.) 

In stained specimens each bacillus shows in its interior one or two 
spores. This bacillus grows on gelatin, forming a delicate white or gray- 
ish layer on the surface, but causes no liquefaction. When cultivated on 
agar-agar and potato it has the appearance of a light-brown, glistening 
layer, which emits a very offensive odor. In mice traces of the culture 
do no harm; the injection of several drops causes septicaemia. Injection 
of about 10 minims of the culture into guinea-pigs causes an abscess, in 
which the bacilli alone are found as pyogenic cause; direct intravenous in- 
jection causes sepsis. 

10. Bacillus Pyocyaneus. — It has been known for a long time that the 
greenish-blue color of the pus, frequently found in the pus of suppurating 
wounds, is due to the presence of a color-producing microbe. The investi- 
gations of Gessard and Charrin, Ernst, Fordos, and Ledderhose have shown 
that this chromogenic microbe is the bacillus pyocyaneus. Freudenreich 
found, as a result of his numerous experiments, that the bacillus pyo- 
cyaneus causes a change in bouillon which renders it unfit for the growth 



236 PRINCIPLES OF SURGERY. 

of other species. In the pus and on solid culture-media the bacilli appear 
in pairs, small groups, or, what is more common, large masses, or zoogloea. 
This bacillus grows upon gelatin, which liquefies and is stained a 
greenish blue. It also grows vigorously on agar-agar and potato, both of 
these substances being stained a greenish hue. In milk it causes caseation, 
with subsequent peptonization of the casein and simultaneous appearance 
of ammonia, while the coloring material appears on the surface in the 
form of greenish-yellow spots. Fordos and Gessard isolated the coloring 
material which this bacillus produces, and called it pyocyanin. It is 



ll 



^sm 



Fig. 92.— Bacillus Pyocyaneus. X 700. 

soluble in chloroform, and from a pure solution crystallizes in long, blue 
needles. Gessard found that a temperature of 57° C, maintained for fixe 
minutes, destroyed the chromogenic power of the bacillus pyocyaneus 
without destroying the vitality of the bacillus, which was propagated 
through successive cultures without regaining this power. 

Fliigge asserts that this bacillus is devoid of pyogenic properties, and 
appears only as a harmless settler upon wounds. Ledderhose, by culti- 
vating this bacillus upon a large scale, obtained a considerable quantity 
of pyocyanin, and by chemical analysis determined its formula to be 






Fig. 93. — Gonococcus. {After Bumm.) 

C 14 H 14 , X 2 C. In doses of 1 gramme, as muriate of pyocyanin, injected 
into the circulation of different animals, he observed no toxic symptoms. 
When a pure culture of the bacilli was injected, he produced suppurative 
inflammation, and attributes this result not to the presence of pyocyanin. 
but to other as yet unknown phlogistic and pyogenic substances elaborated 
by the bacillus in the tissues. 

The practical surgeon looks upon the bacillus pyocyaneus as a com- 
paratively benign pus-microbe, but cases are not wanting in which this 
organism was found as the only microbic cause in diffuse septic processes. 




DIRECT CAUSES OF SUPPURATION. 



231 



This bacillus is normally found in the skin as a saprophyte. It has a 

predilection for certain localities of the body, as the axilla, inguinal 
region, anus. etc. The odor of pus produced by the bacillus is sweetish, 
musty, and at times slightly or very offensive. 

11. Micrococcus Gonorrhoeae. — The micrococcus of gonorrhoea, also 
called gonococcus, was discovered by Xeisscr in 1879, who also demon- 
strated the etiological relationship between this microbe and gonorrhoea. 
Bumm first succeeded in cultivating it upon artificial nutrient media and 
made a special study of its morphology and pathogenesis. The gonococcns 
always occurs in pairs, and is, therefore, a diplococcus. 

The cocci appear as hemispherical bodies with their flattened surfaces 
in apposition, which imparts to the microbe the characteristic biscuit- 




Fig. 94.— Goncrrhceal Pus. 

shaped appearance. The gonococci are found in clusters or clumps upon 

or what is more common, as Bumm asserts — within the pus-corpuscles 

of gonorrheal pus. The microbes within the corpuscle may become so 
numerous as to fill the entire space with the exception of the nucleus. 

The mucous membrane of the urethra and the conjunctiva are the 
localities most predisposed to the pathogenic action of the gonococcus. 
The gonorrheal inflammation, which is at first superficial, penetrates 
more deeply into the mucous membrane with the advancing gonococci, 
which invade the epithelial cells. 

' Bumm, Bockhardt, and others have reported cases of mixed gonor- 
rheal infection in which pus-microbes, acting upon tissues altered by the 
gonorrheal inflammation, gave rise to abscesses in the glands of Bartholin, 



2 38 PRINCIPLES OF SURGERY. 

to cystitis, pelvic cellulitis, and suppurative synovitis. Suppuration in 
joints, peritoneum, and connective tissue the seat of gonorrheal infection 
is prone to occur in the course of secondary infection with more potent 
pyogenic microbes. 

12. Bacillus Coli Communis. — This microbe was first discovered by 
Emmerich, in 1885, in the blood, various organs, and the dejections of 
cholera patients at Xaples. A year later Escherich showed that it is 
constantly present in the alvine discharges of healthy persons. It is a 




Fig. 95. — Gonorrhoea! Conjunctivitis, Second Day of Sickness. Section through the 
mucous membrane of upper eyelid; invasion of the epithelial layer by gonococci. (After 
Bumm.) 

short and thick bacillus (Fig. 96) with rounded ends; the prevailing form 
in culture is a short oval. The bacilli are frequently united in pairs. It 
stains readily with aniline dyes, but is decolorized promptly when treated 
with a solution of iodine. It is an aerobic and facultative anaerobic, non- 
liquefying bacillus. It is non-motile, and does not multiply by spores. 
It grows readily in various culture-media. In gelatin stick cultures the 
growth on the surface is rather dry and thin: in old cultures it covers the 
entire surface. 

Fig. 96.— Bacillus Coli Communis. 

The bacillus coli communis is the most frequent cause of intestinal 
sepsis. It is constantly present in the appendix vermiformis, and is the 
most fruitful source of the different forms of acute and chronic inflam- 
mation of this organ. As this bacillus gains entrance under favorable con- 
ditions into the different ducts and glands in communication with the in- 
testinal canal, it is often the direct cause of suppurative inflammation in 
organs in direct connection or close contact with the intestinal tract, — 
notably the liver and biliary passages. The pyogenic properties of this 



DIRECT CAUSES OF SUPPUBATION. 239 

microbe have been quite recently studied with great care, and pure cult- 
ures have been obtained from abscesses remote from the intestinal tract, 
which proves that it retains its specific pathogenic properties after its 
entrance into the tissues. 

The colon bacillus probably finds its way more frequently into the 
general circulation than any other pathogenic microbes. It is fortunate 
that the organism makes provision for such an event by the creation of 
resisting agencies which often suffice in the prevention of general infec- 
tion. Adami has shown conclusively the bactericidal action of the liver 
upon the colon bacillus. Lemaire points out that, according to Wyssok- 
witch, the liver excretes microbes with the bile, whereas "Werigo and others 
claim that the liver destroys them directly by virtue of the phagocytic 
action of its endothelial cells, which either englobe the microbes directly 



Fig. 97. — 1, white corpuscles from normal blood; 2, pus-corpuscles with cocci in their 
interior; 3, pus-corpuscles with bacilli in their interior. {Koch.) 

or receive them from the leucocytes of the blood. It is the function of 
the endothelial cells of the liver to prevent or retard general infection 
with the colon bacillus, and a colon bacillus which produces general in- 
fection is one which the cells of the liver cannot destroy. This general 
conclusion is supported by the results of the study of phenomena produced 
by injection of colon bacilli in rabbits immunized by means of anticolon- 
bacillus serum. The immunized animals all survived the injection of such 
quantities of both kinds of colon bacilli as was fatal for the control ani- 
mals. The blood of the immunized animals remained sterile, as did the 
spleen and the bone-marrow. Careful microscopical examination failed to 
reveal phagocytosis on the part of the leucocytes; the only place in which 
bacilli were found was in the liver, and the small number present indi- 
cated that ultimatelv total destruction of all bacilli would have taken 



240 PBDsCIPLZ- 01 iUEGEKT. 

showing that the antiinfectious serum aids the action of the endo- 
thelial cells of this organ. Hektoen believes that in the retardation or 
revention of colon-bacillus infection a direct chemical action between the 
antiserum and the toxins of the colon bacillus takes an important part. 
The surgeon meets most frequently with colon-bacillus infection in the 
treatment of perforative peritonitis and cystitis, but there is no organ 
or part of the body exempt from infection with this intestinal microbe. 

IV. PUS. 

Pus is the liquefied product of suppurative inflammation. It can be 
denned as a dead or dying tissue composed of cells with a fluid intercellular 
substance. Pus is an opaque, creamy, yellowish-white or greenish-white 
fluid, which, in a recent state, shows a slightly-acid reaction, and, later, 
becomes alkaline by the formation of ammonia. If it is of a yellowish 
color, creamy consistence, and odorless, it is the pus bonum vel lauddbiU 
of the old authors. If it is thin and intiniately mixed with blood it is 
called sanious or ichorous pus. If it contain but few pus-corpuscles and 
resembles serum, we speak of serous pus. Pus undergoing putrefaction 
from the presence of saprophytic bacteria is rendered fetid, and is then 
termed fetid pus. Pus nixed with the products of tubercular inflamma- 
tion is designated tubercular pus, and if mixed with the secretion of an 
inflamed mucous membrane it is denned as muco-pus. If pus is allowed 
to stand undisturbed for a number of hours in a test-tube, it separates into 
two parts: the upper, the liquid portion, is the pus-serum, or liquor puris, 
while the lower represents the solid constituents of the pus, the pus- 
corpuscle- 

Pus-serum. — The pus-serum contains albumen, a compound called 
pyine, regarded by Mulder as identical with tritoxide of protein, occasion- 
ally ehondrin, glutin, and leucin. abundant fatty matter, and inorganic 
substances si mil ar to those dissolved in the liquor sanguinis. Pus-serum 
contains no oxygen or hydrogen, or if present these gases are found only 
in minute quantities. On the other hand, it contains nitrogen and car- 
bonic acid in large amounts. It contains more potash and soda than blood- 
serum. Among the albuminous substances which it contains are para- 
globin, albuminate of potash, serum, albumen, and myosin. Pus-serum, 
in fact, is liquor sanguinis plus soluble compounds which have developed 
during the inflammatory process: hence it also contains in solution the 
toxins elaborated by the pus-microbes. 

Pus-corpuscles. — The histological sources of pus-corpuscles are 
leucocytes and embryonal cells. In acute inflammation the process if so 
rapid that the pus-corpuscles are derived almost exclusively from leuco- 
cytes. The conversion of a leucocyte into a pus-corpuscle in clinical sup- 



PUS. 241 

proration is invariably accomplished by one or more kinds of pus-microbes, 
which have been described. The pus-microbes constitute the most im- 
portant morphological element of the product of suppurative inflamma- 
tion, being not only diffused between the cells, but also finding their way 
into the interior of the cells. 

All pus-corpuscles show structural changes which indicate disintegra- 
tion. The leucocytes present, as the first evidence of transformation into 
pus-corpuscles, fragmentation of the nucleus. 

Nuclear fragmentation is an entirely different process from karyo- 
kinesis. as it is not, like the latter, an indication of cell-reproduction, but 




yv <& =. s — • ' ^ f ^V :: .; : 







Fig. 98. — Fragmentation of Nucleus in Leucocytes undergoing Transformation into 
Pus-corpuscles. (.Hartnack 3, oc. iv.) (Landerer.) 

of cell-destruction. The nucleus breaks up into two to six or more frag- 
ments, the cell-body still retaining its original form. Fragmentation of 
the nucleus is attended by other forms of intracellular disintegration. 
The protoplasmic strings, which form a living reticulum in the interior 
of the nucleus and cell-body, break up and disintegrate. The embryonal 
cells which are converted into pus-corpuscles undergo similar retrograde 
changes as have been described in the leucocyte. Pus-corpuscles are not 
always of the same size and shape. Their size depends on their histolog- 
ical source. Those derived from leucocytes are somewhat uniform in size. 
while in subacute and chronic suppuration the fixed tissue-cells in a state 
of proliferation furnish a large percentage of the pus-corpuscles, and con- 



242 



PRINCIPLES OF SURGERY. 



sequently their size varies according to the tissue-cells which undergo this 
change. As long as the leucocytes or embryonal tissue-cells are not com- 
pletely destroyed by the pus-microbes or their toxins, they vary greatly 
in their shape. The variation in shape in fresh pus-corpuscles which have 
not completely succumbed to the pus-microbes is due to their amoeboid 





Fig. 100. 

Fig. 99.— Pus with Staphylococcus. X 800. (Fluegge.) 
Fig. 100. — Pus with Streptococcus. (Fluegge.) 

movements. If pus from an acute abscess is examined in a moist chamber 
upon a warm slide, the amoeboid movements of the pus-corpuscles can be 
observed for hours, provided the slide is kept at a proper temperature. 

Pus-corpuscles subjected to the action of acetic acid clear up and 
show their fragmented nucleus much plainer. If pus-corpuscles are mixed 
with water they become larger and hydropic from inhibition of fluids. The 





Q 



Fig. 101. — 1, dead pus-corpuscles; 2, various forms which living pus-corpuscles 
assume by their amoeboid movements; 3, pus-corpuscles acted upon by acetic acid; 4, 
pus-corpuscles after addition of water. X 400. (Billroth-Winiwarter.) 

round pus-corpuscles, according to Eecklinghausen, are dead leucocytes 
or embryonal cells which have lost their amoeboid movements. Liquor 
potassa dissolves the pus-corpuscles, and, if added to fluids containing pus, 
changes them into a gelatinous mass. In chronic abscesses the pus- 
corpuscles undergo molecular degeneration, and such pus under the micro- 
scope shows no well-formed corpuscles, but a mass of granular detritus. 



pus. 243 

If the serum is absorbed, we speak of inspissation of pus. If a wall of cica- 
tricial tissue form around a collection of pus, we say that the pulse has 
become encysted or encapsulated. 

Blue Pus. — Blue pus is produced by the bacillus pyocyaneus: a com- 
paratively mild pus-microbe possessing chromogenic properties. The 
coloring material is imparted to pure cultures and the dressings used in 
the treatment of suppurating wounds in which this microorganism is the 
principal cause of suppuration. 

Bed Pus. — Red pus has recently been described by Ferchmin. It is 
caused by a chromogenic bacillus whose length is about one-third of the 
diameter of a red blood-corpuscle. The bacillus is non-motile and color- 
less, but is readily stained by Gram's method. It can best be cultivated 
upon blood-serum; the cultures have a bright-red color, which later 
changes to violet. 



CHAPTER X. 

Suppuration (continued). 

CLINICAL FORMS OF SUPPURATION. 

In reference to the time required to transform the product of inflam- 
mation into pus, suppuration can be divided into acute, subacute, and 
chronic. 

1. Acute Suppuration. — In acute suppuration the wall of the capillary 
vessels is altered so seriously that emigration of the colorless corpuscles 
takes place with such rapidity that within a few hours the connective- 
tissue spaces are crowded with them, and in a few days the inflammatory 
swelling presents indications of approaching suppuration. The inflam- 
matory product is hard to the touch, and the tissues around it become 
cedematous from obstruction to the plasma-circulation within and in the 
immediate vicinity of the inflamed tissues. The hardness of the swelling 
is due to the infiltration of the connective tissue with leucocytes. In 
this form of suppuration a central ischaemic area is established by the 
rapid accumulation of leucocytes in the connective-tissue spaces and by 
pressure upon the inflamed and weakened capillary vessels, which finally 
leads to complete stasis. The pus-microbes and preformed toxins are 
present in such large quantities that liquefaction of the inflammatory 
product takes place within a few days. The first appearances of suppura- 
tion are observed among the cellular elements which appeared first, which 
corresponds to a point in the centre of the inflammatory swelling, because 
at this point tissue-nutrition has suffered most and the inflammatory 
product has been exposed longest to the deleterious action of the pus- 
microbes and their toxins. The direct causes of conversion of leucocytes 
into pus-corpuscles are the pus-microbes and their toxins, the pathogenic 
action of which on the tissues results in purulent liquefaction of the in- 
flammatory product. Softening in the centre of an inflammatory swelling 
is almost an unerring sign of approaching suppuration. The central sup- 
purating focus increases in size by the extension of the process of liquefac- 
tion in all directions, the leucocytes saturated with the toxins of the pus- 
microbes being rapidly transformed into pus-corpuscles. Acute suppura- 
tion is always accompanied by more or less necrosis of the fixed tissue- 
cells. The acute cell-necrosis is the result of diminished blood-supply 
and the local toxic effect of the chemical products of the pus-microbes. 
Necrosis occurring so constantly from the combined action of these two 
etiological factors in acute suppurative osteomyelitis furnishes a good 

(244) 



CLINICAL FORMS OF SUPPURATION. 2 1 : > 

illustration of this. In phlegmonous inflammation, from the smallest 
furuncle to the largest acute abscess, connective-tissue necrosis is a con- 
stant occurrence, following as an unavoidable sequence of acute suppura- 
tion. Acute suppuration is almost without exception attended by a corn- 
plexus of symptoms, indicating the entrance of phlogistic substances from 
the inflamed tissues into the general circulation, — such as fever, headache, 
thirst, loss of appetite, — which usually subside with the removal of the 
primary cause. Acute osteomyelitis, acute suppurative inflammation of 
the large serous cavities and joints, and phlegmonous inflammation of dif- 
ferent organs are excellent examples of what is understood by acute sup- 
puration, from an etiological, pathological, and clinical stand-point. 

2. Subacute Suppuration. — As acute inflammation may pass into a 
subacute form, so suppuration may be delayed in acute inflammation for 
days and weeks, if the indirect and direct causes which are concerned in 
the transformation of the cellular elements into pus-corpuscles are present, 
less in degree and intensity than in acute suppuration. The character 
and intensity of the primary microbic cause may determine a subacute 
type of inflammation from the beginning, and suppuration is correspond- 
ingly delayed. In subacute suppuration the tissues have more time to 
accommodate themselves to the presence of the inflammatory exudate, 
and hence tissue-necrosis is a less constant occurrence, and, if present, it 
is less extensive. In subacute suppuration, at least, a part of the pus- 
corpuscles are derived from the fixed tissue-cells; while in acute suppura- 
tion central liquefaction of the inflammatory product may take place 
within three or four days, the same stage in the subacute form is often 
not attained in as many weeks. As a rule, the general symptoms are also 
less severe. 

3. Chronic Suppuration. — In acute and subacute suppuration the pus- 
corpuscles are derived, in the former almost exclusively, and in the latter 
largely, from the extravasated leucocytes. With few exceptions, chronic 
suppuration occurs as the result of infection with pus-microbes of a 
preexisting pathological product composed of granulation-tissue. In such 
cases the embryonal tissue is the product of a specific inflammation caused 
by the presence of microorganisms which possess no pyogenic properties, 
but which excite in the tissues a. chronic inflammation, the product of 
which consists of granulation-tissue. The bacillus of tuberculosis, the 
microbe of syphilis, and the actinomyces are good illustrations of this 
class of microbes. If a lesion caused by any of these microbes become the 
seat of infection with pus-microbes, the latter and their toxins are brought 
in contact with cells which are readily converted into pus-corpuscles. In 
chronic suppuration the pus-corpuscles are derived mostly from embryonal 
cells, and consequently they show a greater variety in size and shape than 



246 PRINCIPLES OF SURGERY. 

the pus-corpuscles found in an acute abscess. Purulent liquefaction of a 
mass of granulation-tissue is the characteristic pathological feature of chronic 
suppuration. Embryonal cells derived from any of the fixed tissue-cells are 
converted into pus-corpuscles by the pus-microbes and their toxins in the 
same manner as the leucocytes in an acute abscess, only that this result is 
attained more slowly. In the majority of cases chronic suppuration is the 
result of infection with pus-microbes of a preexisting granulating focus, the 
liquefied portion of which constitutes the contents of the chronic abscess. 
While an acute abscess is often developed in the course of a few days, and a 
subacute in as many weeks, it may require as many months or years for the 
products of a specific inflammation to be transformed into a chronic abscess. 

Chronic suppuration solely due to the pathogenic effects of pus- 
microbes is seen most frequently in the lymphatic glands of the neck and 
axillary spaces. The glands thus affected enlarge very slowly, pain and 
tenderness are slight and several months may elapse before the centre of 
the inflamed gland is converted into an abscess-cavity. We must take it 
for granted that in chronic suppurative parenchymatous rymphadenitis 
the infection is caused by a comparatively small number of pus-microbes 
or that the microbes possess feeble pyogenic properties. In the differen- 
tial diagnosis of chronic affections of isolated lymphatic glands chronic 
suppurative inflammation should always be borne in mind. 

Suppuration in Wounds. — Infection of a recent wound with a suffi- 
cient number of pus-microbes is followed by suppurative inflammation, 
which in its local and general manifestations resembles phlegmonous in- 
flammation as it occurs without a wound. One of the earliest evidences 
that such infection has taken place is a profuse primary wound-secretion. 
This secretion is a mixture of blood and serum, and is secreted in excess 
on account of the inflamed capillaries being more permeable, and yielding- 
more readily to the intravascular pressure. It is also possible that under 
these circumstances closure of the lumen of divided capillary vessels does 
not take place as promptly nor as completely as in aseptic wounds. Sup- 
purative inflammation, when it attacks a recent wound, commences upon 
its surface, with which the microbes have been brought in contact, and 
the products of coagulation-necrosis furnish a favorable soil for their 
growth and reproduction. In such a wound the process of granulation is 
either impeded or completely suspended until the acute symptoms have 
subsided, as the embryonal cells are converted into pus-corpuscles almost 
as soon as they are formed. From the surface of the wound the inflam- 
mation extends to the deeper tissues, the extension being usually along 
the connective tissue, fascia, and intermuscular septa. The parts in the 
immediate vicinity of the wound present the usual appearances of a phleg- 
monous inflammation. The pus which forms first contains dead leuco- 



SUPPURATIVE inflammation OF MUCOUS MEMBRANES. 247 

cyteSj while later the embryonal cells furnish an additional histological 
source for pus-corpuscles. Aseptic granulating wounds are usually con- 
sidered exempt from infection with pus-microbes. While this may be true 
if the whole surface is covered with an uninterrupted, intact layer of 
healthy granulations, it is certainly not the case if the granulations are 
in any way injured or diseased. A slight injury, as probing, may create 
an infection-atrium, through which pus-microbes enter the deeper tis- 
sues, where they may become the cause of a suppurative inflammation. 
Under unfavorable vascular conditions the granulations are rendered 
hydropic, become flabby and anaemic, — conditions which impair their re- 
sistance to the action of pus-microbes, — which then convert the layer of 
embryonal cells most remote from the blood-supply into pus-corpuscles. 
The preformed toxins injure the subadjacent cells, which, in turn, undergo 
the same fate, and thus an unhealthy, infected granulation surface be- 
comes the cause of a secondary suppuration in wounds which indefinitely 
delays the healing process. If in a suppurating wound the pus-microbes 
attack a vein and produce a septic thrombophlebitis, the essential etio- 
logical condition for the occurrence of the most dangerous and intractable 
complication, pyaemia, has been established. 

The disinfection of a suppurating wound still remains an opprobrium 
in surgery. The most faithful attempts' to transform a septic into an 
aseptic wound seldom succeed. This has led some surgeons to advo- 
cate and practice asepsis rather than antisepsis. Zeidler holds that the 
experiments of Schimmelbusch confirm the belief he long entertained, 
that it is practically impossible to destroy the organisms which have 
entered a wound. He thoroughly dissects out all pus-infiltrated tissues, 
wipes with sterile gauze, irrigates with a 6-per-cent. saline solution, packs 
lightly with sterile gauze, and applies a dry, sterile dressing, and when 
this becomes saturated he changes the outer dressing without removing 
the packing. This treatment is applicable when the wound is not large 
and advantageously located; in other cases the antiseptic treatment must 
be relied upon. 

SUPPUEATIVE INFLAMMATION OF MUCOUS MEMBEANES. 

Suppurative inflammation of a mucous membrane is always preceded 
by a catarrhal stage, during which the amount of the physiological secre- 
tion is greatly increased. Proliferation of epithelial cells takes place with 
such great rapidity that the blood-supply becomes inadequate, when the 
most superficial embryonal cells readily succumb to the specific action 
of the pus-microbes and are exfoliated as pus-corpuscles. The toxins be- 
come diffused in advance of the microbic invasion, and, by injuring the 
protoplasm of the cells more deeply located, prepare the way for the 



248 PRINCIPLES OF SURGERY. 

pathogenic action of the pus-microbes, and suppuration extends more 
deeply. In this way ulcers form, which may remain superficial, or which 
may also penetrate deeply and result in perforation. The products of 
coagulation-necrosis which form upon the surface of an inflamed mucous 
membrane favor the occurrence and extension of suppurative lesions, as 
they serve as a means of fixation and propagation of the pus-microbes. 
Pus from a suppurating mucous membrane, examined microscopically, 
will show pus-corpuscles derived from leucocytes and embryonal, epi- 
thelial, and connective-tissue cells which have become detached before 
they are converted into pus-cells. 

ABSCESS. 

An abscess is a collection of pus in the tissues. A collection of 
pus in a preformed space, such as the pleura, pericardium, Fallopian 
tubes, pelves of kidneys, etc., although resulting from a suppurative 
inflammation of the walls lining the space, is by general custom and 
usage not called an abscess, but the presence of pus in any of these organs 
is indicated by the prefix pyo, to which is added the anatomical locality: 
thus, pyothorax, pyopericardium, pyosalpinx, pyonephrosis. The forma- 
tion of an abscess is always preceded by a circumscribed suppurative in- 
flammation. The histological conditions which are present at the time 
pus-formation commences are characterized by a richness of leucoc) 7 tes in 
the connective tissue between the inflamed capillary vessels and compres- 
sion of the preexisting tissue-cells by them and the transuded serum. 

Suppuration commences at one or more points in the infiltrated area; 
if the latter is the case, the different suppurating foci soon become conflu- 
ent, forming an abscess-cavity, which increases in size in all directions, 
both by the products of inflammation breaking down into pus and by the 
mechanical pressure of the exudation and transudation upon the sur- 
rounding tissues. Cheyne, in his excellent article on suppuration, de- 
scribes the changes which precede and attend abscess-formation as fol- 
lows: "Staining sections of tissue in which these plugs are present with 
ordinary aniline dyes, it is found that, while the mass of organisms is 
internally stained, and while the nuclei in the sections have become well 
colored, there is a ring of tissue around the central mass of organisms 
which does not take in the stain and which presents an homogeneous, trans- 
lucent appearance. This ring evidently results from the action of the 
concentrated products of the micrococci, the tissues being brought into 
the condition of coagulation-necrosis. After some hours a second ring 
appears at a greater distance from the mass of organisms, this ring being 
composed of a dense layer of leucocytes apparently collecting where the 
chemical substances are more dilute and do not interfere with the life of 



ABSCESS. 249 

tin* colls. The abscess forms by the central softening of the inflamma- 
tory product and increases by the successive formation of additional rings, 
which undergo, in turn, coagulation-necrosis and suppuration." The size 
of the abscess is determined by the nature of the primary cause of the 
inflammation, its location, and the degree of local and general resistance 
inherent in the tissues and the patient. The staphylococcus is found more 
frequently in circumscribed abscesses, while the streptococcus is more 
prone to give rise to diffuse purulent infiltration. A suppurating focus 
near a surface is not so likely to result in a large abscess as when it is 
more deeply located, as in the former case spontaneous evacuation in the 
direction offering the least resistance is an early occurrence, while in the 
latter instance such a termination is only possible after the abscess has 
reached considerable dimensions. An abscess which develops in tissues 




Fig. 102. — Infiltration of Connective Tissue of Cutis, with Beginning Suppuration 
in the Centre. X 500. {Billroth-Winiicarter.) 

debilitated by a contusion or some antecedent lesions usually reaches 
greater dimensions than if it occur in otherwise healthy tissues. In pa- 
tients whose strength has been impaired by old age, improper or insuffi- 
cient food, intemperance, mental anxiety, or some antecedent acute or 
chronic ailment it is well known that acute suppurative inflammation 
manifests a great tendency to rapid extension; while a vigorous, healthy 
body offers the most favorable conditions toward limitation of the sup- 
purative inflammation. While liquefaction of the inflammatory product 
progresses from the centre toward its periphery, the outer zone of the 
inflamed area is in a condition of hyperemia and active tissue-proliferation. 
The leucocytes beyond the infected area are not converted into pus-corpus- 
cles, and with the products of tissue proliferation constitute an impermeable 
wall, beyond which infection cannot extend. The limit of the abscess is an 



250 



PKINCIPLES OF SURGERY. 



aseptic zone of infiltration, clinically readily recognized by its hardness to 
the sense of touch: the so-called abscess-wall. As many of the small vessels 
in the centre of the abscess are permanently destroyed, a collateral circula- 
tion is established in the abscess-wall and its immediate vicinity by the 
formation of new vessels, as is well shown in Fig. 103. 

According to their contents, the causes, and the 'time which elapsed 
between the commencement of the disease which caused them and their 
formation, abscesses are divided into acute and chronic. 

Acute Abscess. — The acute, or hot, abscess is the usual termination 
of acute, circumscribed, suppurative inflammation. Its favorite location 
is in the connective tissue. It is always caused by infection with pus- 
microbes, most frequently the staphylococcus. It contains the character- 




Fig. 103. — Vessels (Artificially Injected) from Walls of an Abscess Artificially- 
Produced in the Tongue of a Dog. X 25. (Billroth- Winiwarter.) 

istic yellowish, creamy pus, the pus tonum vel laudibile of the old authors, 
and shreds of necrosed connective tissue. It appears within a few days 
after the commencement of the inflammation and reaches its maximum 
size in a short time. It is attended by the typical local and general symp- 
toms which accompany acute suppurative inflammation. Acute abscess in 
the abdominal cavity usually develops after perforation of the intestine 
or one of its appendages; thus, perforation of the gall-bladder often gives 
rise to circumscribed suppuration between the liver, stomach, and colon, 
and perforation of the appendix vermiformis in the right iliac region, where 
the circumscribed collection of pus is called a perityphlitic abscess. The 
loose connective tissue that surrounds the kidney is often the seat of an 
acute suppurative inflammation, giving rise to a perinephritic abscess. 



LBSCESS. 251 

The connective tissue in front of the bladder, the so-called cavum Retzii, 
when it is infected with pus-microbes, occasionally becomes the starting- 
point of an acute abscess. In three cases of abscess in this locality, that 
came under my observation, the infection was caused by a perforation of 
an intestine, and in all of them, after incision, scraping, disinfection, and 
drainage, a faecal fistula developed subsequently. Suppurative parame- 
tritis is another instance of acute abscess, and is usually caused by in- 
fection through the uterine cavity or the Fallopian tubes. Perirectal 
abscesses following suppurative paraproctitis are frequently preceded by 
localized rectal lesions, through which infection of the connective tissue 
surrounding the rectum with pus-microbes takes place. The manner of 
invasion often determines the location and character of the abscess. Thus, in 
suppurative mastitis the abscesses which are caused by staphylococci al- 
ways begin in the deeper part of the organ and extend toward the sur- 
face, while in infection with streptococci of the same part the inflamma- 
tion starts from some superficial abrasion and first attacks the skin, 
whence the process extends in a central direction to the deeper portions 
of the gland, where suppuration takes place (Cheyne). This difference 
depends on the manner of invasion of the two microbes. The staphylo- 
cocci enter the organism through the milk-ducts and act from their in- 
terior; whereas the streptococci, like the microbe of erysipelas, enter the 
tissues through the lymphatic vessels, and their pathogenic action is pri- 
marily observed at the surface. Bumm excised a portion of the wall of a 
commencing abscess of the breast, and was able to demonstrate the pres- 
ence of staphylococci in the interior of the acini, and their penetration 
thence into the interacinous tissue. The phlegmonous inflammation of 
the breast caused by streptococci takes place along the course of the lym- 
phatics, and primarily involves the interacinous connective tissue. 

Diagnosis. — The recognition of an acute abscess is usually not at- 
tended by any great difficulties. The history of an attack of acute sup- 
purative inflammation is the first thing to be taken into consideration. 
Fever is usually present, but if the abscess has been caused by the micro- 
coccus pyogenes tenuis it may be slight or entirely absent. The location 
of the abscess has also considerable influence on the temperature. There 
is no doubt that the same kind and number of pus-microbes in some tis- 
sues produce either a larger quantity of phlogistic substances, or that these 
in some localities and certain tissues find a more ready entrance into the 
circulation. Pain is always present, but is variable in intensity according 
to the location of the abscess and the nature of its surroundings. It is 
severe if the abscess involve parts freely supplied with sensitive nerves, 
and where the inflammatory product gives rise to an unusual degree of 
tension. Thus, a small abscess underneath the deep fascia of a finger will 



252 PEINCIPLES OF SURGERY. 

cause more suffering than a large abscess in loose connective tissue. A 
beginning abscess can usually be accurately located by ascertaining the 
exact point of tenderness on making pressure with the tip of a finger. If 
the abscess is sufficiently near the surface, fluctuation can be felt as soon 
as central liquefaction has occurred. Eedness of the skin and diffuse 
oedema over and around the abscess are important symptoms, denoting 
the presence of pus. Remembering all the symptoms which point to the 
existence of abscess, in doubtful cases an absolute diagnosis should not be 
made by relying upon any one or all of them, as by doing so serious blun- 
ders have been and will be made in treatment. Aneurisms have been in- 
cised under the belief that they were abscesses, and the less serious mis- 
take has been made of treating an abscess for an aneurism. The late 
Professor Gunn, who was well known as a careful and clever diagnostician, 
incised a large angioma in the occipital region, having mistaken it for an 
abscess. An inflammatory swelling occurring in localities where aneu- 
risms are liable to be met with — that is, in the course of large blood-vessels 
— should be examined with the utmost care before an incision is made. 
The most difficult cases "for diagnosis are the few instances where a sup- 
purative inflammation occurs around an aneurismal sac. Fortunately, we 
are in possession of a very simple diagnostic expedient, which, if resorted 
to, as it should be, in all doubtful cases, will enable the surgeon, with in- 
fallible certainty, to ascertain the presence or absence of pus in an in- 
flammatory swelling, and this is the use of the exploring syringe. An 
ordinary hypodermic needle with a long point will answer the purpose, 
although every surgeon should be supplied with an exploring syringe made 
for this special purpose. The needle must be rendered thoroughly aseptic 
by heating it in the flame of an alcohol-lamp, or, still better, by boiling in 
soda solution (1 per cent.). The surface where the puncture is to be made 
is thoroughly disinfected, and the needle is inserted somewhat obliquely 
toward the centre of the swelling and pushed boldly forward in this di- 
rection until resistance ceases, which is an indication that it has reached 
a cavity; the piston of the syringe is now slowly withdrawn and the fluid 
aspirated is examined; if it is pus the diagnosis is made and the needle is 
withdrawn. If no pus is found the exploration is carried deeper, and, if 
necessary, in different directions without removing the needle, by making 
aspiration at different points so as to explore fully the tracks made by 
the needle. If no positive diagnosis can be made it may become necessary 
to repeat this method of examination in a few days. A rapidly-growing 
sarcoma may simulate a suppurative inflammation so closely that great 
care is necessary to distinguish between these affections before any opera- 
tive procedure is advised or undertaken. In exploring for pus in deep- 
seated abscesses in the abdomen or pelvis, care should be exercised to 



ABSCESS. 253 

insert the needle in such a direction, whenever this is possible, as not to 
penetrate the free peritoneal cavity; whenever this cannot be done it 
should be introduced in such manner that, after its removal, the puncture 
is sufficiently oblique to prevent the escape of pus. In such cases it is 
always advisable to combine aspiration with exploration. If the tension 
in the abscess is diminished by removing a portion of its contents extrava- 
sation is less likely to occur. 

Treatment. — A correct diagnosis made, the old rule ubi pus ibi evacuo 
is as applicable to the treatment of an acute abscess at the present time 
as it was centuries ago. Nothing is gained by expectant treatment. The 
popular belief that an abscess should be drawn near the surface by the 
use of filthy poultices before it should be opened is fallacious both in 
theory and practice. An abscess is ready to be opened as soon as an ade- 
quate quantity of pus has formed to constitute an abscess sufficient in 
size to be recognized by the surgeon as such. Students have generally 
been taught that an abscess should be evacuated by a free incision. This 
advice dates back to the time wdien antiseptics were not known and tubu- 
lar drainage had never been heard of. The laying open of an acute abscess 
by an extensive incision is no longer necessary. The indications in the 
surgical treatment of an acute abscess are to open it in such a manner as 
to secure perfect evacuation and to resort to such means as will prevent 
reaccumulation of pus. These indications can be fulfilled much better by 
making multiple small incisions and establishing free drainage by the in- 
sertion of tubular drains than by making a single long incision; at the 
same time, such treatment will leave the parts in better condition for 
rapid healing than by the old-fashioned incisions. The incisions need 
never be more than an inch in length, through which a rubber drainage- 
tube the size of the little finger can be readily introduced. Abscesses up 
to the size of an orange do not require more than one incision. Abscesses 
larger than this should be treated by through drainage wherever this is 
possible. In deep-seated abscesses the first incision is made at a point 
where fluctuation is most distinct, or in the direction of the track of the 
needle of the exploring syringe, if the pus has been located by the use of 
this instrument. Instead of incising the abscess with one stroke of the 
knife I always incise the skin and fascia to the extent of an inch, and then 
with a pair of sharp-pointed haemostatic forceps I tunnel the intervening 
tissues. As soon as the point of the instrument has reached the abscess- 
cavity, pus will escape along the side of the instrument; the handles of 
the forceps are now unlocked and the blades separated sufficiently so that 
upon the withdrawal of the instrument the opening is enlarged sufficiently 
to introduce a drainage-tube of requisite diameter. If counter-openings 
are to be made, the same forceps is carried across the abscess-cavity and 



254 PRINCIPLES OF SURGERY. 

pushed from within outward at a point where drainage is most required, 
the skin over the point is cut with a knife, the opening dilated, and a 
drainage-tube drawn through. The surface over the abscess and a con- 
siderable distance beyond it should be shaved and disinfected before the 
abscess is opened. After incision and drainage the abscess-cavity is 
washed out with a weak antiseptic solution until the fluid returns clear, 
when a moist, hot, antiseptic dressing is applied. After twenty-four or 
forty-eight hours the dressing is removed, the drain shortened, or, if 
through drainage has been made, the drain is cut through in the middle 
and each opening is drained separately. If suppuration has not ceased, 
the cavity is again irrigated. It is seldom that an abscess-cavity heals 
without further suppuration after it has been incised and drained, even 
under the strictest aseptic precautions. The inner lining of the walls 
of the abscess remains infected with pus-microbes, and a limited suppura- 
tion, even in the most favorable cases, continues, at least until after the 
second dressing. The dressings should be so applied as to make equable 
compression, for the purpose of keeping the surfaces of the abscess-cavity 
in accurate apposition. The drainage-tubes are removed as soon as sup- 
puration has ceased, when healing of the aseptic cavity takes place by 
granulation, in the manner described in the healing of wounds. An im- 
portant element in the treatment of abscesses is to secure absolute rest 
for the part affected. Patients suffering from large abscesses should be 
kept in bed, and in the treatment of such affections of one of the extremi- 
ties rest is secured by the application of a well-padded splint, which will 
not only prove an efficient means of mitigating pain, but will keep the 
parts in a condition most conducive to rapid healing. 

CHRONIC ABSCESS. 

A chronic, congestive, cold, or, as it is sometimes called, migrating 
abscess can almost always be traced to some specific chronic inflammation, 
most frequently of a tubercular nature. What has been called a chronic 
abscess is very often no abscess at all. In tubercular processes the 
product of tissue-proliferation undergoes coagulation-necrosis and dis- 
integrates into a granular mass, which, when mixed with a sufficient 
quantity of serum, forms an emulsion that macroscopic-ally resembles 
pus. but under the microscope shows none of the histological elements 
which are found in true pus. .1?? abscess can only be called such if it contain 
pns. A true chronic abscess can originate in a tubercular, actinomycotic, or 
syphilitic lesion when the granulation-tissue is secondarily infected by the 
localization of pus-microbes, which convert the embryonal cells into pus- 
corpuscles. Occasionally secondary infection with pus-microbes of such 
a granulating focus is followed by an acute phlegmonous inflammation, 



( HRONIC ABSCESS. 255 

which extends rapidly to the surrounding tissues; but usually the sup- 
purating process progresses slowly, and is not attended by any of the 
symptoms of acute inflammation. ISliat has been described as a cold abscess 
is a cavity containing the debris of the product of a tubercular inflammation, 
and is usually in communication with the primary tubercular lesion. Such 
abscesses frequently appear at a distance from the primary seat of the dis- 
ease. Thus tuberculosis of the vertebras gives rise to a lumbar abscess if 
the swelling appear in the lumbar region. It is called a psoas abscess if 
the tubercular product gravitate along the course of the psoas muscle and 
appear as an abscess underneath Poupart's ligament. Abscesses origi- 
nating in the hip-joint often make their first appearance over the outer or 
inner aspect of the thigh, some distance below the joint. Abscesses origi- 
nating in the shoulder- joint often wander a considerable distance away 
from the joint, along the course of the biceps or triceps muscle. 

Bacteriological examination of the contents of such abscesses will show 
conclusively whether they are true pus-containing abscesses or whether they 
are pseudo-abscesses. If cultivations are made with their contents, pus- 
microbes will grow upon proper nutrient media if it is a true abscess, while 
from the contents of a pseudo-abscess only the microbes of the primary 
infection can be cultivated. The information obtained by the discovery 
of the essential cause can be confirmed by inoculation experiments. Cold 
abscesses, as a rule, are painless, not tender to the touch, and give rise to 
little or no febrile disturbances. 

Diagnosis. — The diagnosis of a chronic abscess is based not so much 
upon the location, size, and characteristic features of the swelling as a 
careful consideration of the symptoms of the local lesion from which it 
started. Tubercular affections of the spine and hip-joints are accom- 
panied by such well-defined symptoms at the stage when abscesses form 
that the primary lesion can be located without much difficulty. A chronic 
paranephric abscess often develops in the course of a tubercular pyelo- 
nephritis. A tubercular pelvic abscess is frequently associated with pri- 
mary tuberculosis of the Fallopian tube. A chronic abscess often arises 
around a tubercular gland and appears, in consequence of infection with 
pus-microbes, as a chronic suppurative perilymphadenitis. In such cases 
the gland itself has undergone caseation, and is often found extensively 
separated from the surrounding tissues by the suppurative process. In 
reference to the nature of the swelling and the character of its contents, 
an exploratory puncture will furnish positive diagnostic information. 

Treatment. — The indications for early surgical interference in the 
treatment of chronic abscess are not so urgent as in the acute variety. 
These abscesses appear months and often years after the commencement 
of the primary disease. While an acute abscess should always be opened 



256 PRINCIPLES OF SURGERY. 

under aseptic precautions, it becomes a matter of duty and conscience to 
deal with a chronic abscess in a surgical way, only under the strictest and 
most elaborate aseptic precautions. It is a well-known clinical fact that 
when such an abscess opens spontaneously, or is incised in a careless way, 
profuse suppuration and hectic fever follow, with only too often a speedy 
fatal result from septic infection. Additional infection with pus-microbes 
results in the destruction of the granulations which line the cayity, and 
the patient frequently dies from septic infection. Unless the surround- 
ings of the patient admit of carrying out the aseptic treatment to its 
fullest and most perfect extent, a chronic abscess should not be evacuated 
by incision. Tubercular abscess should be treated by tapping and injec- 
tion of iodoform-glycerin emulsion, as this treatment for many years has 
yielded most brilliant results. One great difficulty in evacuating a tuber- 
cular abscess by aspiration is the blocking of the needle or trocar by shreds 
of necrosed tissue, which often interferes with complete evacuation. A 
chronic abscess should always be treated by incision if this treatment fail, 
if by such procedure the primary lesion can be made accessible to direct 
treatment. If such a course is adopted, the incision is made large enough 
so that the whole cavity can be thoroughly scraped out and all of the 
infected tissues removed. After thoroughly curetting the cavity is 
cleansed and disinfected, and after drying it is iodoformized. The wound 
is then sutured, drained, and treated on the same principles as a recent 
wound. The treatment of special forms of chronic abscess will be con- 
sidered more in detail in the chapter on ''Surgical Tuberculosis." 

Phlegmonous Inflammation, with Suppuration. — Phlegmonous inflam- 
mation with suppuration is clinically characterized by rapid extension 
of the disease without leading to a circumscribed collection of pus or 
abscess. From the pus of this form of infection the streptococcus can be 
cultivated more frequently than the staphylococcus, and in some cases 
both of these microbes are found in the same pus. The inflammation 
affects the connective tissue, and extends rapidly along intermuscular 
septa, fascia, and tendon-sheaths. This form of suppurative inflammation 
is prone to follow compound fractures, railroad and other crushing in- 
juries, and all injuries attended by extensive contusion of connective tis- 
sue. It also frequently follows neglected paronychia, punctured and lacer- 
ated wounds of the fingers and hands. The first symptoms usually appear 
within four days after the injury. The general symptoms are ushered iu 
by a chill, followed by high temperature and rapid pulse. The first local 
symptoms are a copious, sanious discharge from the wound and a rapidly- 
spreading oedema. The tissues are infiltrated with the same kind of fluid, 
and if life is prolonged sufficiently long a diffuse suppuration is inevitable. 
The symptoms of sepsis in this affection predominate because the pus- 



PHLEGMONOUS INFLAMMATION, WITH SUPPURATION. 357 

microbes have invaded an extensive area of tissue, and are reproduced with 
great rapidity and gain entrance into the general circulation at an early 
stage; at the same time the necrosed tissues, saturated with the bloody 
serum, furnish a good soil for the growth of putrefactive bacteria. In 
most of these cases the septic cellulitis is accompanied by lymphangitis, 
the parts presenting an erysipelatous appearance. 

Treatment. — Phlegmonous inflammation of the type just described 
calls for early and energetic treatment before suppuration has appeared. 
The pus-microbes are present in such quantities that the connective tissue, 
partially devitalized by an injury, becomes necrosed from the local toxic 
action of the toxins of the pus-microbes. To render such wounds aseptic 
is one of the most difficult tasks in surgery. Small incisions and drainage 
will not accomplish the desired object. The infected tissues must be freely 
exposed by as many incisions as may be required. The secondary disinfec- 
tion in such a case must be regarded in the light of a capital operation. 
The patient should be placed under the influence of an ansesthetic, the 
limb shaved and disinfected, and by large incisions the infected tissues 
must be rendered accessible to direct means of disinfection. Before oper- 
ating, the limb should be rendered bloodless by Esmarclr's constrictor. 

In compound fractures the tissues immediately over the fragments 
should be incised sufficiently so that the fractured ends can be turned 
out. The infected medullary tissue should be scooped out with a sharp 
spoon, and all clots and necrosed tissue removed; the parts are then 
thoroughly irrigated with corrosive sublimate (1 to 1000), or carbolic acid 
(1 to 20), after which the whole surface is dried and brushed over with a 
10-per-cent. solution of chloride of zinc. Pockets and sinuses which 
cannot be reached with the sharp spoon can be rendered aseptic by pour- 
ing in peroxide of hydrogen, which, in such cases, is a remedy of great 
value. The bones are then placed in proper position, a number of counter- 
openings made, and a sufficient number of tubular drains introduced; 
after which a copious antiseptic dressing is applied and the limb properly 
immobilized, great care being taken to prevent decubitus or gangrene from 
pressure by protecting the parts exposed to pressure with sterile or salic- 
ylated cotton. 

During the subsequent treatment such a limb should be slightly ele- 
vated and suspended. If after this treatment the temperature is not low- 
ered within six hours and the remaining symptoms are not improved, 
it is evident that the secondary disinfection has not succeeded in obtain- 
ing an aseptic condition of the wound. If amputation does not appear 
to be indicated at this time, another effort should be made to secure asep- 
ticity by resorting to permanent irrigation. The antiseptic dressing is re- 
moved and not reapplied. The parts are covered with a compress wrung 



258 



PRINCIPLES OF SURGERY. 



out of a y,-per-cent. solution of acetate of aluminum, and constant irri- 
gation made with the same solution. The simplest arrangement for con- 
stant irrigation is a reservoir holding the warm solution suspended over 
the patient's bed, and connected with the principal drainage-tube by 
means of a rubber tubing and a glass tip. In large, open, suppurating 
wounds and compound fractures the apparatus shown in Fig. 104 can be 
used to advantage. By siphon-action the fluid is conducted from the ves- 
sel to every part of the wound. The amount of fluid flowing through the 
tube can be regulated by compressing the tube to the desired extent with 
a clothes-pin. The limb being suspended, the fluid is conducted away from 




Fig. 104. — Irrigating Apparatus. 



it into a vessel by means of a sheet of rubber cloth, mackintosh, or gutta- 
percha. 

Constant irrigation with a harmless, non-toxic, yet efficient antiseptic 
solution in these cases is of the greatest value, as the wound-secretion 
is constantly washed away, and, as no accumulation can take place, the 
danger of sepsis from products of putrefaction is greatly diminished; at 
the same time, the tissues are kept constantly saturated with the solution, 
which at least will exert a potent inhibitory influence upon the action and 
multiplication of pus-microbes in the living tissues. Should a faithful 
attempt at obtaining an aseptic condition by this method of treatment 



PROGRESSIVE PURULENT [NFILTRATION. 259 

prove Lnefficienl after a lair trial, the question of sacrificing a limb, to 
saw. if possible, a life, will preseni itself. 

Helferich has abandoned small incisions and drainage-tubes in the 

Treatment of extensive phlegmonous inflammation and has substituted for 
them laying open of the entire field of inflammation by an incision from 
one end to the other, and after thorough disinfection packs the cavity with 
aseptic gauze saturated with a solution of boric and salicylic acid or acetate 
of aluminum. 

In the absence of recognizable secondary foci in distant organs, the 
surgeon will not be able to ascertain whether a fatal form of general in- 
fection exists in a special case, and it is therefore always justifiable to 
resort to a mutilating operation as a last resort, provided the patient's 
strength warrants such a procedure. As in cases of progressive gangrene, 
so in cases of progressive phlegmonous inflammation, it is exceedingly 
difficult to decide upon the exact location where the amputation should be 
made, as a distinct line of demarcation between healthy and infected 
tissues is never present. The only rule to go by in the selection of the 
site of amputation is to secure healthy skin-flaps and to make the circular 
section of the muscular tissue above the tissues presenting macroscopical 
evidences of infection. The condition of the deep connective tissue fur- 
nishes important information concerning this question. The infection is 
sure to extend as far as any undermining or sloughing of connective 
tissue has taken place; hence, amputation should be done above these 
limits. The general treatment of phlegmonous inflammation is considered 
upon the same principles as the treatment of sepsis from other causes. 

PEOGEESSFVE PTJEULEXT IXFILTEATIOX. 

This is the purulent oedema of Pirogoff. It is a more advanced 
stage of what has just been described as progressive phlegmonous inflam- 
mation with suppuration. Purulent infiltration follows upon the heels of 
phlegmonous inflammation, and is, consequently, clinically also noted for 
its progressive character. The infiltration is often very extensive, involv- 
ing, in many cases, an entire extremity. It is always attended by very 
extensive connective-tissue necrosis. The pus burrows deeply among the 
muscles, and detaches the skin over a large surface. The external ap- 
pearances seldom indicate the extent of the disease. If the skin is in- 
cised freely, the parts beneath — the muscles, vessels, and nerves — appear 
as plainly as in a dissection made to show^ the anatomical relations of 
these parts. Purulent infiltration following progressive phlegmonous in- 
flammation has often been mistaken for erysipelas, and has been called 
phlegmonous erysipelas. If purulent infiltration complicate erysipelas, it 
occurs in consequence of secondary infection with pus-mi crooes, and not as 



•;;: 



PBTSCIPLZ- 01 BTTBGKRY. 



a result of the action of the streptococcus of erysipelas. The gravity of this 

-I::::: ^^L.^ ------i" -? -'- --^ ~ - ~-Z :1: TlSSllr: "_n i~r i. Iz 11 

affect an entire limb the danger to life is great. Death nay occur from 

_ nana :r -T*a-.a—-' -- . 

Trea.neia:. — lar saaraai ::::::.::: is :iaa t.::_7 as :a aisnss. :niy 
:aa: ::: misnns sii aaii :f naif i:n ± aa. :~: :r :_an in: If 5 n ifnaaia. 
in order to enable the operator to remove the necrosed connect. we tissue 

:a: :; insara iaraf a: aa: iaans Aaaar aiaa lias: n::si:n is naif 1 iaa_. 
:aa~ai. Praia aaanas is nnaana. aiaa :avaay naiaaai. mi : : aaaar- : a an- 
:f_: naia a a n aiia a :n: ■:: :iaa af:nn n aia :as nf: : aanna-iaan- 
aaa — 1_ :f n:sa ea:a:n~a. Tiaa nn:; naas: ir iranai 1: iaaaeran: annas 
from one end to the other. If the forceps is not long enough to reach 
a axaaaaiiaaias :: is :ann a ani nsfnf a aaan na: :ia T sa::ni a :na 
a. s: :a aaai aiae an ay :s :i::a:a^iai iaanri. I: :s ainsaiia a: bring 
t: :a "a iiaa: aa-ania na: :z .— : naaaaas ana sa ana fan rai — iaii : sainy- 
n. Iaa nsas :: a a: ana: naalnan.n :: an na: !■:•— n aaaaaaa: I aaa- 
aaa naia as nany as :~ :i~r n:asi:ns ana insaaaai iaaia as naay aaan- 
aaa-nns Aaaea :iaa nan has iaan aa:an nana a. n as ~ asiari out 
— :h :na n aiaa mini naaa: s.naaaaans An axaaiian. siana ::: aa- 



pnrpose is iodinized water. This can he readib 

;: n in: :: snaaiari — ana aaai :iaa saaaaa 
A solution of this strength is a valuable an1 

aaianiaa:.: naananias — iaiana: na: n 
never succeeded in rendering such a large su] 
one irrigation, and have consequently aband* 

a: rssings n aiafsf nsas. i: is nan: ": ::n: : : 
: nn sfiinhn: " :::: a l-aar-nn: saia 
—inn :an if :nn:i aai aaaai faery 

a::ia •: aas. sianaii if in: f~fry aaaar a a ; 
nnsrara 01 aiaa ainairss :an if :a::aaa::: 
n::in nissna :: anniann :i:ai As a: 
- t" -a aaaar fnaian: iranagr aas nan 
ia — aaaiaai ~i:aa aa: a::, ani any men 
nanny na: iy :rea innsin ani :i iaaa: 
n fi~ a~s aansana :: aa a na :.:: aa: : n 
inni :: : snsaansian sain:, i ::ia a: aiaa aar 
::n:a: aaaaaaa As sa :n as naaa::::: a 

n a: a ani irraaaaans naif iass :n 
i:n:~ na: - i: yana. asaaaiaiiy n any :a 
are free from auy other disease, often rally an 
naar aiaan sarenaaia in- aaa if inni :: a 
bodies reduced to a skeleton by the prolonged 



:aai : aiiana aaaaia 
le color of sheny-wine. 

a na na n ana ar- 
ia aaaaaa, i a: a 
ina :a~ i:y nan: nil 
iir : : nan: lannan: 
a : : na 1 an ~aaa_ : 
z anaaia :: annn, 
iir :an:y is naiaaiai. 
aa The warmth and 
:m:na n -nil _ 
of pus often does not 
isiaai. :if aasf siiaaii 



.a sa : a i i : 
iaan: i: 
. a a n an: 



I: a 1 



■ver. 



SUPPURATIVE DBNDO-VAGINITIS. 261 

If suppuration is not controlled by drainage and antiseptic irrigation, and 
especially if the temperature and pulse indicate a continuance of absorp- 
tion of septic material, continuous antiseptic irrigation should be insti- 
tuted, and, if this fail, amputation may become an unavoidable necessity. 
If amputation is decided upon the deep incision must be made beyond the 
limits of the suppurating area. If the suppuration has extended as far 
as the hip-joint it may become necessary to utilize for flaps the skin which 
has been undermined, in order to secure a covering for the stump. If such 
a procedure become necessary the internal surface of the skin-flaps must 
be rendered aseptic by using the sharp spoon and scissors in freeing it from 
infected tissue. During the whole course of the disease, which gives rise 
to purulent infiltration, the patient's strength must be supported by stimu- 
lants and tonics and a concentrated nutritious diet. 

SUPPURATIVE TEXDO-VAGIXITIS. 

Another form of rapidly-spreading inflammation is suppurative tendo- 
vaginitis. As the name implies, it is an acute inflammation of tendon- 
sheaths terminating in suppuration. It occurs most frequently in the 
tendon-sheaths of the fingers, hand, and forearm. It develops usually 
from an infected wound of the finger or hand, or as a complication in 
the different forms of paronychia. The inflammation travels along the 
course of the tendon, starting, perhaps, from one of the tendons of a 
finger, extends to the palm of the hand, underneath the annular liga- 
ment to the flexor muscles of the forearm, where it often produces a 
phlegmonous inflammation which, in the course of time, may involve 
the whole forearm. The tendons are often destroyed, and can be pulled 
out after a few weeks, — an occurrence which is alwa} T s followed by perma- 
nent functional impairment of the affected finger or of the whole 
hand. Xot infrequently suppurative inflammation of a tendon-sheath 
extends to one or more joints over which the tendon passes, causing 
a complication, which often necessitates amputation. This affection is 
always attended by severe pain, and, if extensive, by grave constitutional 
disturbances. The extent of the disease can be ascertained, approximately, 
at least, by the length of the external swelling, and especially by the ten- 
derness along the course of the tendon. Frequently the inflammation at- 
tacks adjacent tendon-sheaths and the pus undermines the entire palmar 
fascia. 

Treatment. — The surgical treatment of suppurative tendo-vaginitis 
must be thorough if it shall be efficient. If it follow in the course of a 
wound, the tendon in the wound is exposed; if it develop during an attack 
of paronychia, it is laid bare by a free incision. Along the course of the 
tendon a curved forceps is passed to the upper limits of the infected part 



262 PRINCIPLES OF SURGERY. 

of the tendon-sheath, another incision is made down upon the point of 
the instrument, and a drainage-tube is drawn through. If the end of the 
suppurating cavity has not been reached the forceps is again introduced 
through the second incision down to the tendon, a third incision made 
higher up, and another drainage-tube drawn through. These manoeuvres 
are repeated until the upper extremity of the suppurating cavity is 
reached. Taking, it for granted that the suppurative tendo-vaginitis com- 
menced in the distal portion of the middle finger, and has reached as far 
as the muscles of the forearm, the first drain should reach as far as the 
metacarpo-phalangeal joint, the second from here to the middle of the 
palm of the hand, the third from here to above the annular ligament, and 
the fourth as far as the middle of the forearm, and if suppuration has ex- 
tended further it will become necessary to extend drainage higher up by 
another drain. If the whole palmar fascia is undermined, a drain should 
be placed transversely across the hand. If the suppuration has extended 
to adjacent tendon-sheaths, more extensive provision for drainage will be 
required. The subsequent treatment is the same as in cases of purulent 
infiltration. Necrosed tendons separate very slowly, but it is better to 
leave their elimination to the granulating process, as it is difficult to de- 
cide how much of the tendon should be removed, and its operative re- 
moval would often require large incisions, which would heal at best only 
slowly, and the large cicatrix would only add to the functional impair- 
ment of the member. From time to time traction can be made upon the 
tendon where it is exposed, so as to remove it as soon as it has become 
partially or completely detached. Passive motion and massage must be 
instituted as soon as the abscess has healed, so as to restore the function 
of the limb as far as is compatible with the existing condition, as not only 
the affected finger, but the whole hand, often will be found to have suf- 
fered seriously from the attack. If one of the principal tendons of a finger 
has sloughed and motion cannot be restored, it is advisable to immobilize 
the finger in a slightly-flexed position, as a curved finger is more service- 
able than a straight one. Suppurative arthritis occurring in the course 
of an attack of tendo-vaginitis often necessitates amputation, more espe- 
cially if it involve more than one joint of a finger. 

PARONYCHIA. 

Paronychia, felon, whitlow, are terms used to designate an abscess 
of a finger. All these terms should be abolished, and abscesses of the 
finger, like of other parts, should be called in accordance with the primary 
disease which caused them. Hueter made a classification upon a strictly 
anatomo-pathological basis. The abscess may be located in the skin, 
and is then a furuncle: it may involve the connective tissue, and is then 



PARONYCHIA. 363 

the product of a phlegmonous inflammation; it may form after an 
attack of periostitis or osteomyelitis, or, finally, it may commence in a 
joint, and is then from the beginning a suppurative arthritis. A sup- 
purative tendo-vaginitis. as a primary affection of a tendon-sheath, has 
often been mistaken for an ordinary felon, and treated as such, with most 
disastrous results. Suppurative tendo-vaginitis is frequently met with 
as a secondary affection of the different pathological conditions which 
give rise to abscess of the fingers. All of the conditions which have been 
enumerated as causes of abscess of the fingers are attended by excruciating 
pain, as the anatomical conditions necessary for the production of this 
symptom — tension and abundant supply of sensitive nerves — are preemi- 
nent in inflammatory affections of the fingers. The pain is of a throbbing 
character, and is always aggravated by placing the hand in a dependent 
position, as the venous congestion produced by this position increases the 
swelling, and consequently the tension, in the inflamed part. 

Treatment. — Volumes have been written on the abortive treatment 
of paronychia: the surest indication that none of the various means sug- 
gested have proved successful. Abscesses of the fingers, as in any other 
part of the body, result only from infection with pus-microbes; hence, 
any measure which falls short of effecting complete sterilization at the 
primary focus of infection must necessarily fail in accomplishing the de- 
sired object. The only rational treatment consists in the employment 
of such measures as will limit the extension of the suppuration. One of 
the most important elements in the early treatment of a felon is to di- 
minish the blood-supply to the inflamed part by placing the limb in an 
elevated position, and by the continued application of cold. The use of 
ice in such a superficial inflammation will not only tend to diminish the 
congestion, but at the same time it has a positive influence in retarding 
the reproduction in the tissues of the primary cause: the pus-microbes. 
Poultices should never be employed. If position and the use of cold do 
not afford relief, moist, hot, antiseptic compresses should be applied. As 
soon as pus has formed it must be liberated by incision. The centre of 
the inflammatory focus is accurately located by marking out by pressure 
the area of tenderness, and the incision is made at this point parallel to 
the long axis of the finger. Scrupulous care must be exercised in render- 
ing the whole surface of the finger aseptic before the incision is made. 
It is not good practice to make the incision invariably down to the bone, 
as the inflammation may not extend to this depth. The incision is only 
carried down to, but not beyond, the suppurating focus; hence, it is made 
down to the bone only if the abscess has originated in a joint or has 
followed an osteomyelitis or periostitis of a phalanx. As the wound gapes 
freely, drainage is not required. The abscess is washed out with an anti- 



264: PRINCIPLES OF SUBGEBY. 

septic solution and the finger dressed antiseptic-ally. Suppurative arthritis 
is treated by through drainage. In osteomyelitis followed by necrosis the 
sequestrum is allowed to separate and is then extracted, which can usually 
be done after three or four week?. Excellent results are obtained after 
the loss of a complete phalanx, as the bone is often reproduced almost to 
perfection by the periosteal sheath. Amputation only becomes necessary 
in cases of osteomyelitis affecting more than one phalanx, complicated by 
suppurative arthritis of the adjacent joints. 

SUPPURATIVE FOLLICULITIS. 

Suppurative folliculitis is a very common affection and represents an 
abscess on the smallest scale. The outlet of the hair-follicle is narrowed 
by the acute inflammation and retention of the secretions, and suppurative 
inflammation is the result of this stenosis. The hair occupies the centre 
of the minute abscess-cavity. The disease appears clinically usually as a 
multiple affection and is well represented by sycosis. 

FUEUXCLE. 

A furuncle is a small abscess of the skin. The centre of a furuncle 
is always occupied by a plug of necrosed connective tissue vulgarly called 
a core. Longard has made a careful microscopico-bacteriological exami- 
nation of 9 cases of furunculosis in young children. In 4 of these cases 
he found the staphylococcus pyogenes albus alone, in 5 cases in com- 
bination with the staphylococcus pyogenes aureus. The identity of these 
microbes with those described by Eosenbach was demonstrated by cultiva- 
tion and experiments on rabbits. The microbes were not found in the 
faecal discharges of the patients, but were discovered, in small numbers, 
in the diapers of healthy, unclean children, as well as in the diapers of 
those suffering from suppurative folliculitis. He believes that the pus- 
microbes are the direct and sole cause of the affection, and that infection 
takes place through the sweat-glands, as the microbes were found in 
abundance upon the inner surface of the membrana propria of these 
glands. As soon as the microbes reach the subcutaneous connective tissue 
they produce suppurative inflammation. Experiments on dogs and rab- 
bits, by cutaneous inoculations with pus-microbes cultivated from the 
furuncles, produced a slight swelling and redness, and. in some instances, 
the formation of small pustules. The result of these inoculations was 
always the same, whether the cultures were made from the pus of a 
furuncle, a suppurating wound that healed without fever, or from a pyae- 
mic patient. The inoculation experiments of Garre, Bockhardt. and 



CARBUNCLE. 265 

Bumm, upon themselves, have been previously referred to, and they prove 
that many of the circumscribed suppurative affections of the skin (among 
them furuncle) are caused by the direct inoculation with pus-microbes, 
which enter the connective tissue either through a slight abrasion or 
through the glands of the skin. Furuncles often appear multiple, either 
in the same region or widely separated from each other over different parts 
of the body. In such cases the successive appearance of furuncles would 
tend to prove the reproduction and diffusion of the primary cause, the pus- 
microbes, over the surface of the body. 

Treatment. — The prophylactic treatment consists in securing for the 
skin a healthy condition. By the free use of hot water and potash-soap 
the openings of the glands of the skin are cleared of accumulation of 
pus-microbes and of materials which might serve as culture substances. 
After thorough cleansing of the skin the surface should be washed either 
with absolute alcohol or a 50-per-cent. solution. In patients suffering 
from furuncle, the slightest abrasions should be treated with care, in 
order to guard against infection. If the general health has been impaired, 
dietetic and medical treatment should be instituted to correct the faulty 
nutrition. We have no special internal remedies to correct a supposed 
suppurative diathesis which does not exist. Sulphide of calcium, which 
has been recommended in such strong terms, has no influence either in the 
prevention or cure of furuncles. With the first appearance of a furuncle, 
the skin over and considerably beyond it should be disinfected, and a com- 
press saturated with a weak antiseptic solution applied. As soon as pus 
appears it is evacuated through a small incision, and if the necrosed tissue 
in its centre has become detached it is extracted. The interior of the 
small abscess is then disinfected and a small antiseptic dressing applied. 
A furuncle is an insignificant lesion, but its proper treatment should 
not be neglected, as numerous cases have been reported where thrombo- 
phlebitis, pyaemia, and acute suppurative osteomyelitis could be traced to 
infection from a, furuncle. 

CARBUNCLE. 

A great deal of confusion has been created in the minds of students 
in reference to what is really meant by a carbuncle. This confusion has 
been brought about by the teachings of some of our text-books, both old 
and recent, which assert that carbuncle is always caused by infection 
with the bacillus of anthrax, while others speak of a less malignant 
form of carbuncle caused by suppurative inflammation. Malignant car- 
buncle, or malignant pustule, is the anthracic form of carbuncle, which 
always starts from a single centre of infection, and is always attended by 
necrosis of the overlying skin. The ordinary carbuncle, which is under 



266 PRINCIPLES OF SURGERY. 

consideration now, is caused by infection with pus-microbes, and differs 
from a furuncle only in so far that it is made up of a number of foci 
of suppuration, which develop simultaneously or in rapid succession, 
and usually become confluent. A carbuncle of this kind is in reality 
nothing else, etiologically and pathologically, but a group of furuncles. A 
section through a carbuncle, before extensive liquefaction has occurred, 
will show a number of foci of suppuration and necrosis, each one of which, 
taken separately, would represent a furuncle. On account of the more 
extensive area of infection in carbuncle than in furuncle, the local symp- 
toms are much more severe. The tissues at an early stage become so ex- 
tensively infiltrated that the carbuncle feels as hard as cartilage. The 
pain, as a rule, is very great. In size, a carbuncle varies greatly; it is 
sometimes not larger than a 25-cent piece, and it may attain a circum- 
ference fully as large as an ordinary soup-plate. The inflammation, which 
first attacks the skin and subcutaneous tissue, in unfavorable cases ex- 
tends to the deeper tissues and also travels in a peripheral direction. If 
the carbuncle is large, the skin covering it becomes gangrenous and ex- 
tensive sloughing takes place. If the carbuncle is small, composed of only 
three or four centres of suppuration, the skin is not destroyed, with the 
exception, perhaps, of a very small portion, corresponding to the apex of 
each furuncular focus. Central necrosis of the connective tissue in each 
suppurating focus invariably occurs, and, if the inflammation is very .se- 
vere and extensive, the whole carbuncle becomes a necrotic mass. In mild 
cases the tissues between the suppurating foci are preserved, and, after 
the elimination of the necrosed tissue, the part presents a cribriform ap- 
pearance, each depression indicating the exact position of the former focus 
of infection. Carbuncle is met with more frequently in persons advanced 
in years and in diabetic patients, and attacks in preference such parts as 
are most exposed to infection from without, as the neck, face, and hands. 
The danger to life connected with carbuncle consists in exhaustion and 
septicaemia, in the progressive form, while thrombophlebitis and pyaemia 
may occur as fatal complications, even if the disease is circumscribed and 
the local symptoms are not severe. 

Diagnosis. — The differential diagnosis consists in separating car- 
buncle from furuncle and malignant pustule, or anthracic pustule. A 
furuncle presents only one centre of suppuration, is more circumscribed, 
more superficial, and not attended by such marked infiltration as car- 
buncle. Malignant pustule is primarily not a suppurative lesion, as it is 
caused by infection with the bacillus of anthrax, and develops from one 
point of infection and gives rise to necrosis of the skin at an early stage. 
Carbuncle starts, simultaneously or in rapid succession, from three to a 
dozen or more suppurating foci, is attended by a hard induration of the 



« LBBUNOLB. 267 

surrounding connective tissue, and gives rise always to multiple foci of 
necrosis of the subcutaneous connective tissue. 

Treatment. — The different methods advised, at various times, to 
abort a carbuncle have not proved more successful than the means sug- 
gested to check the growth of a furuncle. Very recently Beauquinque has 
made the assertion that a carbuncle can be aborted by applying to the part 
antiseptics dissolved in alcohol. He claims to have succeeded in three 
cases by applying tincture of iodine. "While we have no right to question 
the correctness of his diagnosis or the truth of his assertions, it is well 
known that the same treatment has not been attended by the same satis- 
factory results in the hands of other surgeons. It is difficult to conceive 
how the external application of the tincture of iodine or any other anti- 
septic alcoholic solution should have the power to destroy the pus- 
microbes or prevent their reproduction when so deeply buried in the tis- 
sues. The most potent agent to limit the extension of the inflammation 
is the continued application of ice. As soon as pus has formed, the 
different foci of suppuration should be exposed to direct means of disin- 
fection by incising the carbuncle under strict antiseptic precautions. If 
the carbuncle is too large for excision the old-fashioned crucial incision 
answers an excellent purpose in exposing the infected tissues to disinfec- 
tion. The necrosed and infected tissues are removed with a sharp spoon, 
and the surface is disinfected by irrigation with a solution of carbolic acid 
or corrosive sublimate; after which the scraped surface is dried and 
touched with a 10-per-cent. solution of chloride of zinc and the part cov- 
ered with an antiseptic moist compress. If the primary disinfection does 
not arrest further extension of the disease, the whole surface should be 
deeply cauterized with the knife-point of Paquelnr's cautery. After cauter- 
ization a compress saturated with a weak solution of corrosive sublimate 
is to be applied. With the cessation of suppuration granulations appear, 
when the same treatment is to be followed as in the management of granu- 
lating wounds. Septic thrombophlebitis is announced by a well-marked 
chill, followed by the usual grave symptoms which attend pyaemia. If 
the thrombosed vein can be located in such cases it should be removed 
by excision, with a faint hope that, by an early recourse to this expedient, 
a fatal form of pyaemia may possibly be prevented. 

Eieclel has successfully resorted to excision of carbuncle: a method 
of treatment which he strongly recommends. A crucial incision is made 
across the carbuncle and extending well into the healthy tissue. The four 
triangular flaps are then dissected back until healthy tissue is reached, and 
the indurated portion extirpated. The haemorrhage is controlled by com- 
pression. A loose tampon of iodoform gauze is then inserted in the w r ound, 
the skin having been brought back into position. The wound heals 



265 PRINCIPLES OF SURGERY. 

rapidly, and the loss of substance from the centre will replace itself very 
quickly. This operation greatly diminishes the danger of pyaemia and 
shortens the duration of the disease. 

In the treatment of a carbuncle amenable to excision owing to its 
location and size no better treatment can be advised than complete re- 
moval of every vestige of infected tissue with the knife. The author cir- 
cumscribes the infected territory by an incision which penetrates deep 
enough to reach healthy tissue, when the whole mass is removed in one 
piece. The wound is covered by a moist antiseptic compress. 



CHAPTEK XI. 

Ulceration and Fistula. 

ULCER. 

An ulcer is a defect of the cutaneous or mucous surface, characterized 
by an absence of processes pointing to repair and an intrinsic tendency to 
peripheral extension. The process by which an ulcer is produced is called 
ulceration. An ulcer is essentially a surface lesion involving either the 
skin or any of the mucous membranes. The most superficial ulcer is one 
in which only the epithelial layer of the skin or mucous membrane is de- 
stroyed. A deep ulcer is one in which the cause which produced the ulcer 
has penetrated the skin or mucous membrane and has destroyed the sub- 
cutaneous or submucous tissues regardless of their anatomical structure. 
All ulcers are caused and are maintained by pathogenic microbes. They 
are the result of a destructive inflammation, and remain until the primary 
microbic cause has been removed or has been rendered harmless, when 
ulceration yields to regeneration and the ulcer is transformed into a granu- 
lating surface. The transition of an ulcer into a healing surface takes 
place as soon as the embryonal cells on the surface of the ulcer retain their 
vitality and are utilized in the process of repair. At this, the terminal, 
stage of ulceration molecular destruction and suppuration have ceased, 
the granulations are firm, small, and very vascular, and at the margins 
of the granulation field a delicate blue line indicates the beginning of epi- 
dermization. It is impossible to give a satisfactory description of an ulcer 
that will apply to all cases, as the appearance of the ulcer must necessarily 
vary according to the location and its size, the structure of the tissue in- 
volved, and especially the nature of the primary microbic cause and the 
character of the tissue changes in its immediate vicinity. Ulcers of the 
mucous membranes differ from those of the skin, owing to their being 
constantly bathed with the secretions of the affected organ; while the 
products of destruction of an ulcer of the skin frequently become inspis- 
sated and form a crust which may be a valuable protection to the ulcer, 
but which may also become a cause of retention of pus. An ulcer is 
superficial or deep according to the depth to which the microbic cause has 
penetrated and destroyed the tissues. The size of the ulcer is also a sure 
indication of the extent of infection of the affected surface. Eesistance 
to ulceration is not shared alike by all the tissues. The connective tissue 
readily yields to the microbic causes which produce ulceration, while 

(269) 



2 70 PRINCIPLES OF SUEGEBY. 

muscles, bone, cartilage, and especially blood-vessels offer greater resist- 
ance. TJie microbes constantly found upon the surface and the tissues 
of an ulcer, irrespective of the primary cause, are the pus-microbes. Every 
ulcer represents an open, suppurating inflammation. In tuberculosis, 
gumma, lepra, and actinomycosis of any of the surfaces mixed infection 
with pus-microbes invariably takes place as soon as a surface defect has 
occurred, and the suppurative lesion which follows as the result of the 
mixed infection always greatly modifies and frequently overshadows the 
primary infection. The exposure of tumor-tissue to external infection is 
followed by a similar complication. Vascular disturbances, such as are 
caused by atheroma of the arteries and varicose veins, are not only frequent 
and potent causes in the production of ulceration, but exert at the same time 
a very deleterious influence upon the nutrition of the tissues in the immedi- 
ate vicinity of the ulcer. In the description of an ulcer special attention is 
given to its floor and margins. The floor of every ulcer is covered by 
what are generally called "unhealthy granulations." The granulations 
are either scanty or very abundant: in the latter case they are said to be 
fungous. They are flabby, often pale and cedematous. and exhibit the de- 
structive effect of the pus-microbes and their toxins. The superficial em- 
bryonal cells are transformed into pus-corpuscles as long as the microbic 
causes which produce the ulcer remain active. The products of coagula- 
tion-necrosis are often deposited upon the surface of the ulcer in the form 
of a membrane more or less firmly attached to the granulations. 

Membranous deposits are found more frequently upon ulcerated sur- 
faces of mucous membranes than upon ulcers of the skin. In ulcerating 
malignant tumors the surface of the ulcer is occupied by exposed tumor- 
tissue, the seat of infection with pus-microbes and often also with bacilli 
of putrefaction. The fcetor of the discharges from ulcers is always due to 
the presence of putrefactive bacilli, which feed upon the dead tissue and 
live and multiply in the retained secretions. Induration of the base and 
margin of the ulcer is always suggestive of carcinoma. In chronic ulcers 
the underlying and adjacent tissues are often extensively infiltrated and 
dense, but this firmness and density is something quite different from the 
circumscribed, almost cartilaginous induration that characterizes the car- 
cinomatous ulcer. In varicose ulcers the whole leg is often cedematous and 
hard. The margins of an ulcer are abrupt when the floor of the ulcer cor- 
responds in size with its surface. If the margins are undermined, the floor 
of the ulcer is larger than its surface, while the reverse is the case when 
the margins are everted or sloping. In reference to kind, an ulcer is either 
acute or chronic. An acute ulcer is the result of a trauma, burn, frost-bite, 
followed by suppurative infection, or of an acute suppurative inflammation 
which has resulted in a surface defect. A chronic ulcer is one of the results 



I L< BE. Wi 1 

trf a chronic inflammation like tuberculosis or syphilitic infection, or it fol- 
lows localized impaired nutrition, the consequence of prolonged mechanical 
causes which interfere with a proper blood-supply, as is the case in ulcers 
caused by varicose veins or atheroma of arteries. In shape an ulcer may be 
round, oval, linear, or serpiginous. An ulcer is frequently called in accord- 
ance with the primary cause which produced it, and we speak of an ulcer 
being traumatic, syphilitic, tubercular, carcinomatous, malignant, varicose, 
mercurial, etc. The clinical behavior of an ulcer is often described by such 
Terms as irritable ulcer, inflamed ulcer, phagedenic ulcer, etc., the adjec- 
tives having reference to the most prominent symptoms presented by the 
ulcer. Among the general causes which favor ulcerative processes must 
be enumerated anaemia, acute infectious diseases, diseases of the cerebro- 
spinal centres, atheroma, varicose veins; organic disease of the heart, kid- 
neys, and liver; and scurvy. 

Diagnosis. — The differentiation between the different kinds of ulcers 
is often an easy, but occasionally a very difficult, task. A correct diagnosis 
is an essential prerequisite to successful treatment. In obscure cases it 
is very important to obtain an accurate and reliable clinical history with 
special reference to the nature of the primary lesion. In ulcers compli- 
cating malignant disease it is usually not difficult to ascertain the ex- 
istence and nature of the primary affection. Acute suppurative affections, 
with or without injury, followed by surface defects which refuse to heal, 
result in ulcers the cause and nature of which can be readily ascertained. 
Fleers following the action of caustics, burns, and frost-bite offer no diffi- 
culties in diagnosis. The most obscure ulcers follow defective innervation, 
and develop as secondary lesions in the course of different forms of chronic 
infective diseases, notably tuberculosis and syphilis. In ulcers due to con- 
genital or acquired syphilis the cautious observer can usually find other 
indications of syphilis, and should make careful search for hyperplasia of 
the lymphatic glands, especially those of the occipital region and of the 
forearm, so constantly present in cases of constitutional syphilis. In 
tuberculosis of the skin and mucous membranes and the different forms of 
lupus the ulceration is usually preceded by nodules, and these can gener- 
ally be found in the vicinity of the tubercular ulcer. In cases of doubt 
in the differential diagnosis between tuberculosis, syphilis, and carcinoma, 
the microscope and inoculation experiments will render valuable service. 
The microscope can be relied upon in making a positive diagnosis between 
carcinoma and the different forms of granulomata if the sections are taken 
from the most recent and active part of the growth. Inoculation experi- 
ments can be relied upon in making a differential diagnosis between syphi- 
lis and tuberculosis, as the inoculation will prove negative in the former 
and will yield a positive result in the latter affection. 



272 PRINCIPLES OF SURGERY. 

Treatment. — The indications which, must be met in the treatment of 
an ulcer are: 1. Eemoval of the primary essential cause. 2. Eemoval of 
indirect cause. 3. Eest. 4. Skin-grafting. The first indication is readily 
complied with if the ulceration depend upon mechanical causes which ad- 
mit of removal. An ulcer of the mucous membrane caused by a sharp, 
projecting margin of a tooth or fragment of a carious tooth will heal 
promptly upon the removal of the source of irritation. A varicose ulcer 
will heal in a short time if the patient is placed in a recumbent position 
with the limb elevated. A syphilitic ulcer, as a rule, yields kindly to a 
vigorous antisyphilitic treatment. As ulceration is always caused by in- 
fection with pus-microbes, a vigorous antiseptic treatment of the ulcer- 
ated surface is best calculated to transform an ulcer into a healthy, granu- 
lating surface. Nothing has yielded better results in my hands, in accom- 
plishing this object, than a saturated solution of acetate of aluminum. 
The vicinity of the ulcer should first be thoroughly disinfected by shaving 
and scrubbing with warm water and potash-soap, after which the ulcer is 
covered by a thick compress of gauze wrung out in a warm solution of 
acetate of aluminum. Evaporation is prevented by applying over the com- 
press gutta-percha tissue, mackintosh cloth, or waxed paper. If the granu- 
lations are very flabby a 10-per-cent. solution of chloride of zinc should be 
applied every three or four days. The compress should be kept moist and 
changed daily. The removal of indirect causes calls for medicinal agents 
and dietetics calculated to improve the general condition of the patient 
and remove the primary affection. In tubercular ulcerations it is neces- 
sary to remove by excision, if possible, all of the tubercular tissue. In 
malignant ulcers the removal of the primary tumor fulfills this indica- 
tion. In the treatment of ulcers of the lower extremities the first thing 
to be done is to confine the patient to his bed and place the affected limb 
in an elevated position. This part of the treatment insures rest for the 
affected limb and exerts the most direct influence in correcting the vas- 
cular disturbances. As soon as the ulcer has been rendered aseptic cica- 
trization and epidermization should be hastened by skin-grafting. This, 
according to the size of the ulcer, can be successfully done either by Eever- 
din's or Thiersch's method. If the ulcer is aseptic preliminary scraping 
is not only unnecessary, but harmful. 

The patient must be cautioned not to use the limb too soon after a 
successful skin-transplantation, as the new tissue at best is but an imper- 
fect substitute for normal skin. Careful protection of the new skin by 
aseptic hygroscopic cotton and the wearing of elastic-webbing bandage 
must be continued several weeks or months after the most successful skin- 
grafting, in order to prevent recurrence of ulceration. 



FISTULA. "iT:> 



FISTULA. 



A fistula is a tubular ulcer. It always communicates with the pri- 
mary Lesion ami marks the course of the suppurative affection which pro- 
duced it. The existence of the fistula is the surest indication of the per- 
sist once of the primary cause. When it communicates with a hollow viscus 
it gives exit to part of the secretion of that organ, and is called, according 
to the communicating organ, a bronchial, pleural, gastric, intestinal, 
vesical, rectal, uterine, etc., fistula. If it lead to a deep-seated primary 
tubercular affection it is called a tubercular fistula. Tubercular fistula 
always folloAvs the spontaneous perforation or incision of a tubercular 
abscess which fails to heal, and is always paved its entire length by tuber- 
cular granulations. Many fistulae in communication with internal organs 
persist in consequence of an obstruction the removal of which is followed 
by closure of the fistulous tr#ct. The remarks on the etiology, diagnosis, 
and treatment of ulcer are applicable to fistula, with the exception that 
ulceration is a superficial process, while the presence of a fistula indicates 
the existence of a deep-seated primary lesion which must he reached and 
removed before the conditions necessary for the successful treatment of 
the fistula are established. 



CHAPTER XII. 

Suppurative Osteomyelitis. 

Suppurative inflammation of the marrow of bone is an exceedingly 
frequent affection in children and young adults. As a primary disease it is 
seldom met with after the skeleton has become fully developed. The form 
of osteomyelitis that will be considered here is the so-called spontaneous 
variety, which occurs without direct exposure of the medulla to infective 
microorganisms from without. 

HISTORY. 

Traumatic osteomyelitis following amputation, compound fractures, or 
gunshot injuries of the bones has been recognized for a long time as a dis- 
tinct and serious wound complication, but osteomyelitis occurring without 
such injuries was not understood until quite recently. We find no mention 
of this acute affection of bone until 1705, when J. L. Petit gave a descrip- 
tion of an acute disease of the long bones which corresponds with what we 
now understand by osteomyelitis. Similar allusions have been made to it by 
Gooch, Pott, Cheselden, Hey, and Abernethy, some of their descriptions be- 
ing sufficiently accurate to enable us to recognize the character of the lesion. 
In 1831 M. Eenaud published a paper on "Inflammation of the Medullary 
Tissue of the Long Bones," in which he gives a report of five cases occurring 
after amputation, all having terminated fatally. 

Cruveilhier alludes to the remote consequence of this affection when 
he says: "The phlebitis of the bones is one of the most frequent causes of 
visceral abscesses following wounds or surgical operations in which the bones 
are involved." Eoux credits Nelaton with having devised the term osteo- 
myelitis in 1834, and having published a brief account of it in 1844. In 1849 
Mr. Stanley, in his excellent monograph on "Diseases of the Bones," gave an 
accurate account of the spontaneous variety under the title "Suppuration in 
Bone." In 1855 Chassaignac applied the term osteomyelitis for the first time 
to the spontaneous variety, reporting at the same time four cases that came 
under his own observation. Among the surgeons who have increased our 
knowledge of the traumatic variety, the names of Vallette, M. Eoux, Jules 
Eoux, Larrey, Pirogoff, Lidell, and Allen deserve well-merited mention. In 
1865 W. Eoser gave a complete resume, in thirty propositions of what was 
then known concerning the spontaneous variety. On account of the multi- 
plicity of the bone affection, and the frequency with which the joints are 
involved, he called the disease "pseudorheumatism." The infectious origin 
of traumatic osteomyelitis has been recognized for a long time, but the spon- 

(274) 



BACTERIOLOGICAL \\l> EXPERIMENTAL INVESTIGATIONS. 275 

taneous form was believed to be purely inflammatory until Luecke first called 
attention to its infectious character. Demme, Yolkmann, Schede, and 
Hueter have added valuable contributions to the modern literature of non- 
traumatic acute suppurative osteomyelitis. Pasteur detected in osteomyelitic 
pus a microbe which he claimed was identical with the microbe found in 
furuncles; hence he spoke of osteomyelitis as "furuncle of bone." The bac- 
teriological and experimental researches of Kocher, Bosenbach, Passet, 
Krause, and Kraske have established the fact that non-traumatic osteomye- 
litis, like the traumatic f orm, is a suppurative inflammation of the medullary 
tissue, caused invariably by infection with pus-microbes. Primary suppura- 
tion in bone begins in the medullary tissue; hence it is not correct to speak of 
a suppurative ostitis, as is so frequently clone among English and American 
authors. Primary suppurative periostitis is an exceedingly rare affection; 
consequently, osteomyelitis must be considered as the most frequent of all acute 
inflammatory diseases of bone. 

BACTERIOLOGICAL AND EXPERIMENTAL INVESTIGATIONS. 

Active suppurative inflammation in bone, when it occurs independently 
of an external wound, and consequently of direct infection, furnishes one of 
the most interesting, and, thanks to the patient and persevering investiga- 
tions of a number of the foremost pathologists, one of the best-known forms 
of purulent infection. For years it has been contended, by some who made 
the etiology of acute osteomyelitis the subject of experimentation, that it is 
caused by a specific microbe not found in other forms of suppuration. Con- 
vincing evidence, however, has accumulated, which seems to leave no further 
doubt that the ordinary microbes of suppuration are the cause of this form 
of suppurative inflammation, and that the gravity of the symptoms which 
attended the disease, as compared with other suppurative processes, is owing 
to the anatomical location and structure of the inflamed tissues, rather than 
to any difference in the microbic cause. Even before the microbic cause of 
acute osteomyelitis was understood, Kocher believed that infection, in some 
cases at least, occurred through the intestinal canal, and made some experi- 
ments to prove this point. He produced subcutaneous fractures artificially 
in dogs, and then fed the animals large quantities of putrid material, and, 
in some cases, succeeded in causing suppuration at the seat of injury. In his 
clinical experience he also observed that in many cases of acute suppurative 
osteomyelitis the premonitory symptoms pointed to the gastro-intestinal 
canal as the povtio imasionis. 

Bosenbach cultivated the staphylococcus from osteomyelitic pus as early 
as 1881. In one case the yellow and the white staphylococcus were found 
together, in another case the staphylococcus alone, while in a third case the 
aureus and the streptococcus pyogenes were cultivated from the same pus. 



276 PRINCIPLES OF SURGERY. 

Eosenbach produced the same result in his experiments by injection of a pure 
culture of pus-microbes from a furuncle of the lip, as Struck did with cultiva- 
tions from the pus of osteomyelitis, and with osteomyelitic pus injected into 
the subcutaneous connective tissue he produced an ordinary abscess. Recur- 
rent attacks of osteomyelitis, years after the primary disease had been ap- 
parently cured, Eosenbach explains by assuming that after the first attack 
some of the microbes remain in the tissues in a latent condition until, at 
some subsequent time, local conditions are created which enable them again 
to display their specific pathogenic properties. Struck obtained, from the 
pus of an acute case of osteomyelitis, upon gelatin, an orange-yellow culture; 
the identity of this culture with the staphylococcus pyogenes aureus was 
soon generally recognized. By injecting a pure culture into the circulation 
of animals which had been subjected, a few days before, to injury of bone, 
as contusion or fracture, he produced a suppurative inflammation at the seat 
of the trauma. Krause cultivated from osteomyelitic pus the staphylococcus 
pyogenes aureus and albus, which he also found in the effusion of joints, when 
this occurred as a complication of the disease. Injection of a pure culture 
of these cocci into the peritoneal cavity of animals caused suppurative peri- 
tonitis. Intravenous injections, with or without previous fracture, were fol- 
lowed most frequently by suppuration in joints and muscles. If a bone was 
fractured subcutaneously before the injection was made, he frequently ob- 
served suppuration at the seat of fracture, and from the pus the staphylococ- 
cus could again be cultivated. Foci in the kidneys were always present in 
all of these experiments. Miiller succeeded in cultivating the staphylococcus 
pyogenes aureus from the yellow granulations in cases of acute epiphyseary 
osteomyelitis. Eodet succeeded in producing in animals suppurative osteo- 
myelitis by intravenous injections of pus-microbes, without inflicting an 
osseous injury. The suppuration, which was generally circumscribed, was 
usually located near the epiphysis; it seldom involved any considerable por- 
tion of the shaft. In many cases separation of the epiphysis and suppurative 
arthritis of the adjacent joint occurred. In the most acute cases the animal 
died within twenty-four hours, without any appreciable changes in the bones 
being demonstrable at the necropsy. Young animals proved more susceptible 
to inoculations. Eodet believes that primary localization of the pus-mi- 
crobes takes place in the medullary tissue at a point close to the epiphyseal 
cartilage. When separation of the epiphysis occurred, the pathological fract- 
ure was always found on the side of the diaphysis. 

Lannelongue made investigations concerning the bacteriology of acute 
osteomyelitis in 35 cases. The staphylococcus pyogenes aureus was found 
to be the immediate cause in 21, the staphylococcus pyogenes albus in 7, the 
streptococcus pyogenes in 3, the pneumococcus in 2, and in 2 the specific 
microbe could not be ascertained. He claims that it is possible to distinguish 



BACTERIOLOGICAL AND EXPERIMENTAL [INVESTIGATIONS. 277 

by the symptoms between streptococcous and Btaphylococcous osteomye- 
litis, the fever in the former being more irregular, the skin over the affected 
region much redder, with Lymphangitis and painful adenitis. The metastases 
due to the streptococcus are articular, synovial, and serous, while those caused 
by the staphylococcus are visceral. Staphylococcus is more frequently met 
with in young children. The streptococcous infection is less liable to give 
rise to extensive necrosis than implication of soft parts. In osteomyelitis 
produced by the pneumococcus suppurative arthritis w T as a constant compli- 
cation. 

Rhine, who failed in producing metastatic abscesses with pure cultures 
of pus-microbes, rendered four rabbits pyaemic by injecting osteomyelitic pus 
directly into the venous circulation. He used the pus taken from a case of 
acute osteomyelitis with grave symptoms, and diluted it with distilled w r ater, 
and of such a mixture he injected a Pravaz syringeful into one of the auricu- 
lar veins of four rabbits. One died in twenty-four hours, with symptoms of 
toxaemia, and the autopsy showed nothing but a beginning pneumonia of left 
lung. The other three animals died seven to ten days after the injection, and 
in all of them suppurating foci were found in the kidneys and the muscles 
of the heart. Xo abscess in muscles or suppuration in joints. The plate 
cultures made from the pus used for the experiments showed the staphylo- 
coccus pyogenes aureus and albus and the bacillus pyocyaneus. With the ex- 
ception of the albus, all of the microbes were also cultivated from the pus 
of the metastatic abscesses. In a later communication the same author ex- 
presses the opinion that the indirect causes of suppurative osteomyelitis are 
changes brought about in the medullary tissue by the microbes and their 
ptomaines of general febrile diseases, such as typhus, scarlatina, diphtheria, 
etc., which prepare the soil for the action of pus-microbes, or the disease is 
produced by the direct extension from a localized suppurative lesion, as a 
furuncle, through the lymphatic vessels, or along vessel- or nerve- sheaths to 
the medullary tissue. 

Jordan found in the osteomyelitic pus, in 3 cases, pneumococci; while 
in 6 other cases the disease was caused by the typhoid bacillus. According 
to the same author, the suppurative inflammation of the medullary tissue 
may also be caused, in exceptional cases, by the micrococcus pyogenes tenuis, 
the bacterium coli commune, the bacillus pyocyaneus, and the micrococcus 
tetragenus. Lannelongue and Achard found in osteomyelitic pus the diplo- 
coccus pneumoniae of Fraenkel as the only and essential microbic cause of 
the inflammation. E. Fischer and Levy found the same microbe in the pus 
and blood of 2 children suffering from osteomyelitis. 

Kraske has studied, from a clinical stand-point, the manner of infection 
in cases of acute osteomyelitis. In one case he could trace the infection dis- 
tinctly to a furuncle of the lip; but, as a rule, he thinks that infection takes 



278 PRINCIPLES OF SURGERY. 

place through a wound or abrasion of the skin. Infection through the intes- 
tinal canal he considers possible, but not proved; more frequently it takes 
place through the respiratory organs, and in one case he could locate the in- 
fection through this route with certainty. He asserts that recurring attacks 
should not always be looked upon as the result of former infection, but as a 
consequence of a new infection of the old site. 

CAUSES. 

The essential exciting cause of suppurative osteomyelitis, both acute 
and chronic, is the presence of one or more varieties of pus-microbes. Direct 
extension of a suppurative lesion through the medium of lymphatic vessel- 
or nerve- sheaths, as Einne suggests, may be possible, but such a direct 
connection between a peripheral suppurating focus and a central osseous 
lesion of a similar nature can seldom be demonstrated. Infection in most 
instances takes place by pus-microbes which have found their way into the cir- 
culation from a suppurating wound or through the respiratory or intestinal 
mucous membrane, and which localize in the medullary tissue prepared for their 
reception by anatomical peculiarities of the capillary vessels, or by a locus 
minoris resistentiai created by an injury or some antecedent pathological con- 
dition. A number of well-authenticated cases have been reported where a 
subcutaneous fracture became the starting-point of an attack of osteomyelitis 
in patients who suffered at the same time from a suppurating wound in a part 
distant from the fracture. In such cases it is reasonable and logical to assume 
that pus-microbes enter the circulation and are conveyed by the blood-current 
to the seat 'of fracture, where they are arrested and find a favorable soil for their 
reproduction and the exercise of their pathogenic properties. Such cases are 
simply the counterpart of what has been accomplished by experimentation. 
Clinical experience and experimental research have shown that pus-microbes 
localize in preference near the epiphyseary lines of the long bones. During the 
growth of bone this region is supplied with new, growing, and imperfectly- 
developed capillary vessels: a condition which cannot fail in favoring local- 
ization of floating microorganisms in this locality. Neumann has also called 
attention to a peculiarity of the capillary vessels in the medullary tissue, their 
calibre being four times greater than that of the arterial branches that sup- 
ply them: another important anatomical condition which predisposes to 
localization of microbes in this tissue. Histological investigation has also 
shown that the small blood-vessels in the medullary tissue are devoid of a 
proper vessel-wall, and appear more like channels or excavations than blood- 
vessels: another condition which must yield a potent influence in determin- 
ing congestion in these vessels and mural implantation of infected leucocytes 
under the action of an exciting cause or causes. As Luecke has shown, and 
as Einne again asserts, the medullary tissue is prepared for the action of pus- 



SYMPTOMS. 279 

microbes by the causes which precipitate an attack of some acute febrile af- 
fection, as variola, typhoid fever, scarlatina, rubeola, and diphtheria. Keen 
has given a good account of all the bone-lesions following the continued 
fevers. He found 69 cases, of which 22 affected the head, 7 the trunk, 6 the 
upper and 42 the lower extremities. In 37 cases the disease followed typhoid 
fever. As to the date of occurrence in 47 cases, 10 were within two weeks, 
27 from three to six weeks, and 10 some months after the fever. Keen's ex- 
planation was that the earlier cases probably resulted from thrombosis and 
the later from enfeebled nutrition. Trauma, if any, in these cases was always 
slight. Children and young adults who have passed through an attack of 
any one of these infectious diseases are strongly predisposed to an attack of 
acute suppurative osteomyelitis. Excluding all such influences, there is still 
left a large number of cases where osteomyelitis attacks persons otherwise 
apparently in perfect health. My own observations induce me to attribute 
to exposure to cold an important role as an exciting cause. I do not wish it 
to be understood that exposure to cold alone could ever result in an attack 
of acute suppuration of the medullary tissue. Pus-microbes inhabit persons 
in perfect health, and they do not cause disease as long as the circulation re- 
mains normal, as localization does not take place in the absence of a proper 
soil. If, however, in such a person the circulation in the medullary tissue 
is disturbed suddenly, in consequence of a sudden or prolonged chilling of 
the surface of the body, congestion, mural implantation and localization of 
the floating pus-microbes occur in a locality which offers the least resistance 
in such an emergency, and a suppurative inflammation is established in the 
medullary tissue. I have repeatedly observed cases of osteomyelitis in boys 
who, after active exercise, suddenly became chilled by bathing in cold water, 
or who, after an exciting game of base-ball, stretched themselves out on the 
cold ground to rest. A disturbance of the equilibrium of the circulation from 
any cause is an important factor not only in precipitating an attack of acute 
osteomyelitis, but many other local infective processes in persons already in- 
fected with the essential cause. 

SYMPTOMS. 

Acute suppurative osteomyelitis is usually ushered in by a chill and 
other symptoms indicative of the commencement of an acute suppurative 
affection. In some cases, even during the earliest stages, the general symp- 
toms are out of all proportion to the local lesion, presenting a clinical picture 
characteristic of intense septic intoxication. I have observed several cases 
of multiple osteomyelitis where the patients passed into a typhoid condition, 
muttering delirium, dry tongue, diarrhoea, and a continued form of fever, 
with a high temperature and rapid pulse, and died within a week, before 
the local disease had made any considerable progress. In one of these cases 



280 PRINCIPLES OF SURGERY. 

the patient was a young lady, 18 years of age, in whom the disease affected 
both tibiae, one femur, both humeri, one clavicle, and several ribs from the 
very beginning, and the disease proved fatal on the sixth day. In such cases 
the prominent general symptoms are those of a malignant form of progress- 
ive sepsis. It is possible that the toxins produced by the pus-microbes in the 
medullary tissue may be more virulent, or that they are produced in larger 
quantities than in suppurative inflammation of other organs. Again, the 
toxins gain here more ready entrance into the circulation, as, at least in part, 
they are produced within the blood-vessels, and the extravascular products 
are forced rapidly into the circulation on account of the unyielding nature of 
the tissues around the primary focus of inflammation. In some cases of acute 
osteomyelitis the actual development of the disease is preceded by premoni- 
tory symptoms, which indicate the route through which infection has prob- 
ably taken place. A preceding bronchial catarrh would indicate the pos- 
sibility that infection had occurred through the mucous membrane of the 
respiratory organs, while infection through the intestinal canal would give 
rise to diarrhoea as a premonitory symptom. The local symptoms will be 
considered separately, as a correct early diagnosis can only be made by a care- 
ful study of these, individually and collectively. 

Pain. — Pain is one of the earliest and constant symptoms af acute osteo- 
myelitis. It may be absent in multiple osteomyelitis, where the patient passes 
into a condition of stupor almost from the beginning. The pain is described 
by the patient as being excruciating, of a boring, tearing, or throbbing char- 
acter. It is not limited to the area involved by the disease, but is often dif- 
fuse, extending to the adjacent joint and over a considerable portion of the 
shaft. It is caused by the great tension resulting from the pressure of the 
inflammatory product in a tissue surrounded by an unyielding case of com- 
pact bone. Pain increases as the exudation becomes more abundant, and is 
diminished or subsides almost completely with the escape of the inflamma- 
tory product from the interior of the bone into the surrounding soft tissues. 
Sudden diminution of pain is almost a certain indication that perforation of 
the bone has occurred, and that the pus has escaped into the loose paraperi- 
osteal tissues. The location of pain should be carefully inquired into, as in 
multiple osteomyelitis this symptom will show, at an early time, the number 
and location of bones affected. In multiple osteomyelitis the disease may 
appear simultaneously in several bones far apart, or the disease appears in 
one bone first,' and other bones are attacked later successively. The appear- 
ance of pain in a new locality is generally an indication that another bone 
has become involved. 

Tenderness. — The patient is very seldom able to locate accurately the 
primary focus of the disease in an inflamed bone, as the pain is diffuse; but 
the pain caused by pressure will enable the surgeon to locate the primary 



B"5 MI'TOMS. 28] 

focus within the bone with accuracy, vxcu before any external swelling has 
appeared. During the first few days the area of tenderness will correspond to 

the extent of the disease in the interior of the hone, and the centre of this urea 
will correspond to the primary focus of the inflammation. Tenderness is most 
acute where the disease has approached nearest the surface of the hone, and 
by this means the surgeon locates the site for early operation. Tenderness 
is caused by the secondary periostitis. In osteomyelitis of the long bones 
this symptom appears first Dear one of the epiphyses, and extends later 
toward the shaft of the bone as the periostitis ascends or descends in that 
direction. 

Swelling. — The absence of external swelling during the first few days 
of an attack of acute osteomyelitis has often given rise to mistakes in diag- 
nosis. As the primary inflammation is located in the interior of a bone, ex- 
ternal swelling is absent until the inflammation has extended to the sur- 
rounding soft tissues. With the appearance of the secondary periostitis 
swelling occurs, which at first can be felt as a hard induration, soon followed 
by oedema and deep-seated fluctuation. The rapid local diffusion of the 
process is largely due to the unyielding nature of the tissues around the 
primary focus, and to the fact that the blood-vessels are directly concerned 
in the extension of the process by becoming the channels for the diffusion 
of the septic infection, their contents forming a nutrient medium for the 
pus-microbes. Thrombophlebitis is a constant and early condition in every 
case of acute osteomyelitis. The oedema of the soft parts is caused, in part 
at least, by the deep-seated venous obstruction. The external swelling sel- 
dom appears before the end of the first week, but when it once shows itself it 
increases very rapidly. The secondary suppurative periostitis results in ex- 
tensive denudation of the bone of this membrane, a large portion of the shaft 
being surrounded by pus. As soon as the suppurative inflammation extends 
to the soft tissues, diffuse burrowing of pus takes place between the bone and 
the periosteum and among the muscles. Within a few days an immense 
abscess or a very extensive purulent infiltration develops in this manner. 

Redness. — The skin over the affected bone presents a pale, normal ap- 
pearance until the pus reaches the subcutaneous tissue, when it presents a 
red or brownish-red discoloration. The superficial veins are always dilated 
and turgid: a reliable indication of the existence of a deep-seated thrombo- 
phlebitis. 

Synovitis. — Inflammation of joints situated in close proximity to osteo- 
myelitic foci is the rule. Catarrhal synovitis appears during the first few 
weeks, while suppurative synovitis usually occurs later as a complication of 
acute suppurative osteomyelitis. If the effusion into the joint is of a serous 
character, it occurs not as a result of infection with pus-microbes, but in con- 
sequence of vascular disturbances outside the limits of the area of infection. 



282 



PRINCIPLES OF SURGERY. 



The serous effusion appears rapidly, gives rise to pain and contraction of the 
joint, but. as a rule, disappears spontaneously after the evacuation of pus. 
Suppurative synovitis follows infection of a joint with the same microbes 
that caused the osteomyelitis, which reached the joint either directly, 
through some pathological defect of the epiphysis, or through the lym- 
phatics or blood-vessels. 

The occurrence of an attack of suppurative synovitis greatly aggravates 




Pig 105. — Osteomyelitis of the Tibia in a Girl S Years Old, Two Weeks after Beginning 
of the Disease, showing Location and Extent of the Denuded Bone. 



the general symptoms, and is attended by more serious local disturbances 
than is the case if the effusion is of a non-septic character. If any doubt exist 
in reference to the character of the effusion an exploratory puncture will 
furnish the necessary information. 

Epiphyseolysis. — Separation of an epiphysis from the diaphysis in the 
epiphyseal line is not an infrequent accident in cases of osteomyelitis of the 
long bones. It is a pathological fracture which occurs in consequence of 



DIAGNOSIS. 283 

necrosis, inflammatory osteoporosis, or molecular disintegration of bone in 
the epiphyseary line. It is readily recognized by the existence of a false 
point of motion and the displacements which usually attend fractures in 
such a locality. Epiphyseolysis seldom occurs before the end of the fourth 
or sixth week from the beginning of the attack. 

Loss of Function. — In a limb the seat of an acute osteomyelitis all func- 
tions are usually completely suspended. It is as useless as though one of the 
principal bones had been fractured. The patient is unable to raise it, or to 
move the nearest joint. The limb is not only useless, but the patient com- 
plains of a sensation as though it would break on its being lifted or otherwise 
manipulated. 

DIAGNOSIS. 

Mr. Holmes has well said that acute suppurative osteomyelitis is more 
frequently recognized at post-mortem examinations than at the bedside of 
the sick. It has often been mistaken and treated for other affections, as 
periostitis, ostitis, inflammation of joints, rheumatism, typhoid fever, ery- 
sipelas, and even phlegmonous inflammation of the soft parts. When we 
remember that periostitis, ostitis, synovitis, and cellulitis are secondary 
lesions, intimately associated in the clinical history of every case of osteo- 
myelitis, and, furthermore, that the fever attending it closely resembles 
typhoid fever, it is not surprising that mistakes in the early diagnosis of this 
disease are not infrequent, even in the practice of experienced surgeons. A 
careful consideration of every feature of the clinical picture presented by 
each case can only enable us to arrive at correct diagnostic conclusions. 
There is no single pathognomonic symptom that would infallibly lead us to 
a correct diagnosis. The presence of fat-globules in the pus was regarded 
as diagnostic by Chassaignac and Roser. Fat-globules are often found in 
osteomyelitic pus, but they are not invariably present, and may also occur 
in the pus of a phlegmonous inflammation. An important element in dif- 
ferential diagnosis is the absence of external swelling for the first few days, 
regardless of the severity of other symptoms; also, its rapid diffusion after 
it has once made its appearance. In periostitis and phlegmonous inflamma- 
tion of the connective tissue swelling is one of the earliest symptoms. In 
osteomyelitis the superficial swelling is at first cedematous, extends sym- 
metrically around the entire bone, and gradually diminishes at a point where 
the morbid process in the interior of the bone has become arrested. In acute 
cases fluctuation appears about the end of the first or during the second week. 
A consecutive inflammation of proximal joints usually makes its appearance 
about from the end of the first to the fourth week. The time of its appear- 
ance, as well as its character, is determined by the causes which produce the 
synovitis. While joint affections are almost constant in osteomyelitis, they 



284 



PRINCIPLES OF SURGERY. 



are seldom associated with periostitis, or plastic osteomyelitis. In osteomye- 
litis of the tibia the phlegmonous inflammation sometimes involves the 
prepatellar bursa, in which case the swelling simulates very closely a com- 
plicating suppurative synovitis. The fluctuation over the knee-joint is, how- 
ever, in such cases continuous with that of the primary osteomyelitic abscess. 
The character of the fever which accompanies grave attacks of osteomyelitis 
sometimes obscures the local symptoms to such an extent as to lead the at- 
tendant to the belief that the patient is suffering from an attack of typhoid 
fever. Goltdammer has reported a typical case of this kind. The general 
symptoms simulated typhoid fever so closely that the patient, after an ill- 
ness of ten days, was sent to the medical wards as a severe case of typhoid 




Fig. 106. — Osteomyelitis of Tibia Two Weeks Old, Complicated by Extension of 
Phlegmonous Inflammation to the Prsepatellar Bursa. 



fever. The pulse ranged between 110 and 120: temperature, 40° to 41° C, 
with tympanites, dry tongue, enlargement of spleen, bronchitis, rapid respi- 
ration, and delirium. On close examination, a slight swelling was found over 
the lower part of -the right tibia, with tenderness on pressure: symptoms 
which finally enabled the attending physician to make a correct diagnosis. 
During the progress of the case pleuritis, parotitis duplex, and synovitis of 
the right shoulder- joint made their appearance. The patient died eight days 
after admission, or eighteen days from the beginning of the disease. The ne- 
cropsy revealed the existence of acute osteomyelitis of the tibia and pyaemia. 
Many such cases have been recorded where the differential diagnosis between 
acute osteomyelitis and typhoid fever was difficult, if not impossible, until 
the local symptoms became more conspicuous. The premonitory symptoms 



PROGNOSIS. 285 

in typhoid fever are more constanl and prominent than In osteomyelitis. In 
the Latter affection the bronchia] or intestinal catarrh which occasionally 
precedes the attack constitutes the only premonitory symptom which has 

been observed, and. as a rule, the disease commences abruptly without any 
such warnings. Chassaignac believes that diarrhoea is present in almost all 
cases in the beginning, hut it is a more constant symptom after septicaemia 
and pyaemia have made their appearance. The temperature, as a rule, shows 
less variation in osteomyelitis than in typhoid fever. After the initial chill 
and the usual symptoms attending the subsequent fever, the first symptom 
that points to osteomyelitis is pain. This is generally severe, deep-seated, 
constant, boring, tearing, or throbbing in character, and referred to the pri- 
mary focus of the disease, usually in the vicinity of the epiphyseal line. 
Patients old enough to describe their sensations complain of a feeling as if 
the bone were being broken. They object to moving or handling of the 
limb on account of fear of an aggravation of this distressing sensation. E. 
von Wahl makes the statement that fluctuation is at first circumscribed in 
phlegmonous inflammation of the connective tissue, while it is diffuse from 
the beginning in osteomyelitis. This distinction is a good one. The im- 
portance of searching for points of tenderness in the diagnosis and location 
of the disease has already been alluded to. The differential diagnosis be- 
tween rheumatism, gonorrhceal arthritis, and osteomyelitis is not difficult, 
as in the former diseases the joint affections occur as a primary disease, while 
in osteomyelitis they appear as complications. 

PROGNOSIS. 

Modern aggressive surgery has greatly diminished the mortality of acute 
osteomyelitis. Under the old, expectant, non-antiseptic treatment it was 
large. Thus, Demme lost 1 out of 17 cases; Luecke, 11 out of 24; Kocher, 
9 out of 26; and Schede, 3 out of 23 cases. Multiple osteomyelitis, with 
grave symptoms of septicaemia from the beginning, almost without exception 
proves fatal in less than two weeks. Death in such cases is caused by pro- 
gressive sepsis resulting from the entrance of large quantities of toxins into 
the circulation. After death no characteristic macroscopical lesion can be 
found in distant organs, and microscopical examination reveals only the 
minute changes in the capillary vessels typical of acute septicaemia. If the 
patient escape this, the first source of clanger to life, he is still exposed, dur- 
ing the existence of the acute symptoms, to the more remote risks incident 
to the presence of septic thrombophlebitis. If any of the thrombi undergo 
softening and disintegration, fragments reach the general circulation and 
constitute infected emboli, which establish in distant organs, notably the 
lungs and kidneys, independent centres of suppuration, — the so-called 



286 PRINCIPLES OF SURGERY. 

metastatic or pyaamic abscesses. The accession of this fatal complication is 
announced by recurring chills, an intermittent form of fever, and is followed 
within a short time by death from sepsis or exhaustion. Another fatal acci- 
dent which may occur is fat-embolism. The medullary tissue is liquefied by 
the suppurative inflammation, and some of the free fat-globules may be 
forced into the circulation by the intraosseous pressure, and death is pre- 
ceded b}^ rapid, shallow breathing; cyanosis; small, rapid pulse: symptoms 
which point to the existence of an obstruction to the passage of the blood 
from the right to the left side of the heart. Extensive destruction of the 
medullary tissue is always followed by marked anaemia, and this condition 
is a prominent symptom in all cases of osteomyelitis, as this disease seriously 
impairs the function of the myeloid tissue, one of the important blood- 
producing organs. Schede has seen, in cases of acute osteomyelitis, the 
proportion of the white to the red blood-corpuscles increased to 1-100. 
The clinical thermometer is an important prognostic aid in this as well 
as in many other acute infective processes. If the morning and evening 
temperature remain continuously high, — that is to say, ranges from 
40° to 40.5° C. during the first week, — it indicates a severe case. The 
more the general symptoms resemble a severe case of typhoid fever, the 
graver the prognosis. The occurrence of decubitus is always an unfavor- 
able sign. In regard to the function of the limb after an attack of acute 
osteomyelitis, a few words are necessary. Necrosis of the bone, to a 
greater or less extent, is the rule. The extent of periosteal detachment 
during the acute stage is no indication of the area of subsequent seques- 
tration, as the greater part of the denuded bone may receive an adequate 
blood-supply from the vessels within the bone, and soon becomes covered 
with granulations, and later unites with the periosteum or the paraperiosteal 
tissues. Joint affections and partial or complete separation of one or more 
epiphyses are frequent complications. A catarrhal effusion is generally re- 
moved by absorption after the subsidence of the acute symptoms, and the 
functions of the joints are restored completely. If the effusion is sero-puru- 
lent and the articular cartilages remain intact, aspiration, with subsequent 
washing out of the joint with an antiseptic solution, may be sufficient to re- 
move the effusion and restore the usefulness of the limb. Stiffness of the 
joint and malposition of the articular surfaces of the bones are events that 
cannot be avoided in all cases, even by the most skillful and attentive treat- 
ment. If the articular cartilages are destroyed by suppurative arthritis, the 
best result that can be hoped for is a useful limb with ankylosis of the joint. 
Pathological fractures through the shaft of a. bone or epiphyseolysis are 
complications which greatly tax the duties of the attending surgeon, but 
from which the patients frequently recover with useful limbs. 




Fig. 107 



-Osteomyelitis of the Radius. Enlargement of the entire bone and 
three well-defined abscess-cavities. 



PATHOLOGICAL ANATOMY. 38' 



PATHOLOGICAL ANATOMY. 



Acute osteomyelitis is essentially a phlegmonous inflammation of the 
marrow of bone. This disease attacks, preferably, the long bones, although 
the scapula, clavicle, ribs, and ilium are also frequently affected, especially 
in cases of multiple osteomyelitis. Of the long bones the femur is most fre- 
quently affected. Seventy-three per cent, of all of Demme's cases involved 
this bone. In the femur the disease manifests a special predilection for the 
lower epiphyseal region, while in the tibia the order of frequency is reversed. 
The great frequency with which the extremities of the shaft of the long 
bones are affected receives a plausible explanation from the activity of the 
physiological changes during the growth of bone, and perhaps to a lesser ex- 
tent by the greater frequency of traumatism in these localities. Englisch 
claimed that the extremity of the shaft and epiphysis, toward which the 
nutrient artery is directed, is always primarily affected, on account of the 
greater blood-pressure in that locality. Clinical experience has proved the 
contrary. As acute osteomyelitis, without direct exposure of the marrow, 
is caused by infection with pus-microbes, which reach the tissue through the 
circulation, the inflammatory process must commence in the capillaries from 
mural implantation of microbes or leucocytes containing them. 

The cause of the inflammation is primarily endovascular, and reaches 
the medullary tissue with the leucocytes. Intense alteration of the capillary 
wall is always present in these cases, giving rise to rhexis. Pus from acute 
osteomyelitis almost always presents a reddish appearance, which is owed to 
the presence of extravasated blood. Oilier has described an inflammatory 
affection of bone under the term "periostitis albuminosa." This name was 
suggested owing to the character of the inflammatory product, which is of 
a viscid nature resembling turbid synovial fluid. Oilier believed that this 
pathological variety of osteomyelitis commenced in the periosteum, and was 
distinct from the ordinary variety etiologically. Krause and others on in- 
vestigating the bacteriology of the albuminous product found that it con- 
tained staphylococci, consequently the same microbes so constantly found 
in osteomyelitic pus. The bone disease described by Oilier is a mild form 
of osteomyelitis characterized clinically by the absence of severe local and 
constitutional symptoms and pathologically by the nature of the inflamma- 
tory product and the limited sequestration. In the acute variety of osteo- 
myelitis the inflammation extends rapidly to the larger veins, which become 
blocked by the formation of a thrombus. If pus-microbes enter the throm- 
bosed veins in sufficient quantity to cause liquefaction of the coagulated 
blood, pyaemia results from transportation of fragments of such infected 
thrombi to distant organs. Extensive thrombophlebitis results in arrest of 
circulation in portions of the bone, or perhaps of the entire shaft, which is 



288 



PRINCIPLES OF SURGERY. 



Mffl 



wg. 



Fig. 108. — Necrosis of Hu- 
merus; Sequestrum inclosed by 
Involucrum. (After Lebert.) 



followed by the usual consequences of such a 
condition: necrosis. Necrosis is undoubtedly 
also caused by the local toxic effect of the tox- 
ins of the pus-microbes upon the tissues and the 
pressure resulting from the presence of the in- 
flammatory exudate in a tissue not capable of 
distension. By the coalescence of numerous 
small foci of pus the central medullary cavity 
is rapidly transformed into an abscess-cavity. 
The pus occupies either the entire cavity, a cer- 
tain section of it, or is in the form of multiple 
circumscribed abscesses or infiltration. The 
infection from the central focus extends along 
the blood-vessels and soon reaches the perios- 
teum, which becomes the seat of an inflamma- 
tion which resembles, pathological^, the pri- 
mary medullar}' lesion in every respect. The 
secondary periostitis in every case of acute 
osteomyelitis always assumes a suppurative type. 
Pus accumulates between the periosteum and 
bone, causing often extensive denudation of 
the bone. The periosteum at some points is 
destroyed when the pus reaches the surrounding 
connective tissue, which then becomes the seat 
of a phlegmonous inflammation. The perios- 
teal defects are not restored subsequently, and 
at these points openings remain later in the 
new bone, called cloacae. After the active 
symptoms have subsided the suppurative peri- 
ostitis gives way to a process of repair, during 
which the periosteum forms a case of new bone 
around the necrosed portion, which, in tech- 
nical language, is called an irmolucrum. The 
abscess in the soft parts heals, and one or 
more fistulous communications between the sur- 
face of the skin and the dead bone in the. interior 
of the involucrum remain. The external open- 
ings are often quite distant from the cloacae, and 
in such cases it is difficult, if not impossible, to 
discover the dead bone by probing. The ne- 
crosed bone is called a sequestrum . If necrosis 
has occurred at different points several sequestra 



PATHOLOGICAL ANATOMY. 



289 



will be included by the involucrum. Separation of a sequestrum, like the 
elimination of necrosed sofl tissues, is accomplished either by suppuration 
or, what is more common, by granulation. Such pieces of bone always show 
an irregular or dentated outline, which is due either to the original shape of 
the sequestrum or to the action of the granulations, which diminish the size 
of the detached bone after its separation. Necrosis is said to be central if 
the sequestrum is composed of tissue from the interior of the bone, com- 
plete if it represent the entire thickness of the bone, and cortical if it is com- 
posed of the external compact layer only. In complete necrosis a patholog- 
ical fracture necessarily takes place if separation occur before a firm involu- 




Fig. 109.— Sequestra following Acute Diffuse Suppurative Osteomyelitis. 
(Pathological Museum of Rush Medical College.) 



crum has formed. In such cases restoration of the continuity of the bone is 
effected by the new bone. In central necrosis the dead bone is always en- 
cased in an involucrum. In cortical necrosis' spontaneous elimination of the 
sequestrum frequently occurs if the bone separate before an involucrum 
forms around it, or, if an involucrum does not form, on account of destruc- 
tion of a corresponding portion of the periosteum. 

The medullary canal in the new bone, after central or total necrosis, is 
seldom restored to perfection. The new bone is harder and heavier than 
normal bone (osteosclerosis), but in exceptional cases it remains porous and 
soft (osteoporosis): a condition described by Volkmann and Schede, which 



290 



PRINCIPLES OF SURGERY. 



may become the cause of various degrees of deformity, from bending of the 
shaft. Separation of a sequestrum will take place in from four weeks to 
three months, according to the age of the patient and the location and extent 
of the necrosis. 



TREATMENT. 



An early and correct diagnosis is of the greatest importance in the treat- 
ment of acute osteomyelitis. As the gastrointestinal canal is undoubtedly 




Fig. 110.— Hollow, Padded, Posterior Splint. (Esmarch.) 

more frequently the route through which infection takes place than is gen- 
erally supposed, and, as Nature's resources often attempt elimination of the 
pathogenic microorganisms in this direction, it would appear rational to ad- 
minister a brisk cathartic soon after the appearance of the first symptoms, 




Fig. 111.— Board Splint for Upper Extremity. (Esmarch.) 

as such treatment might prove of great value in arresting further infection 
from this source. A large dose of calomel, administered for the same pur- 
pose and in the same manner as advised during the early stage of typhoid 
fever, could not fail to produce a salutary effect, Kocher has advised the in- 
ternal use of salicylate of soda, giving from 6 to 24 grammes in divided doses 



TREATMENT. 



291 



during twenty-four hours. In such doses this remedy would also have some 
effect in reducing the temperature, which is constantly high in all acute 
cases. Opium must be given in sufficient doses to alleviate pain. The af- 
fected limb should be immobilized and placed in a slightly elevated position. 

Demme, Billroth, and Volkmann recommend vesication by frequently 
repeated applications of the strong tincture of iodine. It is doubtful if such 
treatment has any influence in arresting or even retarding the further devel- 
opment of the disease. The use of the ice-bag is rational, and often relieves 
pain. In multiple osteomyelitis, with pronounced symptoms of progressive 
sepsis almost from the beginning of the attack, it is doubtful whether any 
surgical treatment will have any effect in preventing a fatal termination. In 
such cases general infection occurs almost from the very beginning, and at 
the necropsy very little, if any, pus is found in the inflamed medullary tis- 
sue. The indicatio vital is in these cases calls for the use of stimulants. 

One of the most important duties of the surgeon, in taking charge of 




Fig. 112.— Wire Splint. (Esmarch.) 



a recent case of osteomyelitis of any of the long bones, is to secure rest and 
elevation of the affected limb. For the lower extremity a hollow, well- 
padded, posterior splint, shown in Fig. 110, will answer an excellent purpose. 
For the upper extremity a wire or board splint will secure the necessary de- 
gree of immobilization. Immobilization of the limb in proper position from 
the very beginning of the attack of osteomyelitis is the most efficient prophy- 
lactic measure against contractures of joints, which follow so often as remote 
complications. An excellent method of immobilization of a limb after an 
early operation for osteomyelitis consists in the application of an interrupted 
plaster-of-Paris splint, as shown in Fig. 113. The two parts of the plaster- 
of-Paris splint are connected by a posterior wooden splint, which is incorpo- 
rated in the plaster dressing by packing the spaces between the splint and 
the surface of the limb. By covering the splint and its packed margins with 
shellac varnish it is rendered impermeable to antiseptic solutions. 

In regard to the propriety of making early incisions the greatest diver- 



292 



PRINCIPLES OF SURGERY. 



sity of opinion lias prevailed in the past. Previous to the researches of 
Demme, early and free incisions were practiced very generally. As the re- 
sults following the treatment were frequently disastrous, Demme was led to 
adopt a more conservative course. He advised an expectant plan to be pur- 
sued until the disease should exhaust itself, as it were, as indicated by re- 
duction of temperature and cessation of the active symptoms of the inflam- 
mation, and then he argued the propriety of making large incisions. For 
the purpose of affording an outlet for the pus Klose made early and small 
incisions at the junction of the epiphysis with the diaphysis. Oilier advo- 
cates early incision, combined with trephining of the bone. In a commu- 
nication, read before the Academy of Paris, he claims that trephining is 




Fig. U3.— Interrupted Plaster-of-Paris Splint. 



applicable to all forms of osteomyelitis with severe general symptoms. He 
maintains that trephining, even in the most diffuse form, will arrest the in- 
tense pain by relieving pressure; and where the disease is circumscribed it 
affords prompt and decided relief. In the acute form, he claims, trephining 
will often prevent extensive necrosis and fatal symptoms, while in the sub- 
acute and chronic form it removes the most distressing symptom: pain. In 
8 out of 19 cases of early trephining he found pus; and in 10 cases the mar- 
row presented different morbid appearances; while in the last case, a case of 
acute osteomyelitis of the femur, a large quantity of fluid blood escaped. 
Two of the 19 cases died of pyaemia. 

Since osteomyelitis has been recognized as a microbic disease, attempts 



i im: \ imi:\ r. ^93 

have been made to arrest it by intraosseous injections of germicidal 
solutions. Hueter has employed parenchymatous injections of solutions of 
carbolic acid with decided benefit in the treatment of other inflammatory 
affections of bones and soft tissues, Kocher recommended that the soft tis- 
sues around the infected bone should be disinfected by saturating them with 
a solution of carbolic acid, thrown in with an ordinary hypodermic syringe. 
Later, the same author suggested the propriety of making intraosseous in- 
jections after penetrating the bone with a small perforator and injecting 
carbolized water, thus reaching the primary focus of the disease. Theoretic- 
ally, the suggestion appears valuable; practically, intraosseous injections in 
the treatment of acute suppurative osteomyelitis have proved a failure. If 
it is next to impossible to abort even a small circumscribed suppurative in- 
flammation in the soft tissues with antiseptic parenchymatous injections, it 
is not surprising to learn that the same treatment has invariably failed in 
arresting suppuration in the interior of bones. Intraosseous injections are 
no longer used in the treatment of acute suppurative osteomyelitis. 

Antiseptic surgery has revolutionized the treatment of acute suppura- 
tive osteomyelitis. The diseased medulla is now attacked with the same im- 
punity as the soft tissues outside of the bones. The objections to large in- 
cisions increasing the danger from sepsis and pyaemia are no longer well 
founded, as incisions made under antiseptic precautions for the evacuation 
of pus, instead of increasing the risks of death from sepsis or pyaemia, are 
now considered the best means to prevent these fatal complications. 

It can now be laid down as an axiom in surgery that the medullary cav- 
ity, in every case of acute suppurative osteomyelitis, should be freely exposed 
and submitted to direct and most thorough antiseptic treatment as soon as a 
positive diagnosis can be made. It would be a serious and unjustifiable mis- 
take to open a healthy medullary cavity; but, on the other hand, it would 
also be next to criminal negligence to wait for fluctuation before resorting to 
operative treatment in a case of acute osteomyelitis. The bone should be 
opened, the infected medulla removed, and the cavity disinfected before 
suppuration has extended to the periosteum and the surrounding soft tissues. 
The intelligence and moral courage of a surgeon can be nowhere better tested 
and gauged than when he is confronted by a recent case of acute osteomye- 
litis. He must be sure of his diagnosis, and this often requires no ordinary 
erudition and diagnostic skill. A positive diagnosis made, he must possess 
enough courage to face the popular prejudice against early operation under 
circumstances where success is not always attainable. Impressed with the 
imperative necessity of operative interference from his knowledge of a case, 
a conscientious surgeon will not flinch from his duty, even under the most 
unpromising circumstances. If the responsibilities and risks are great, he 
will do well to fortify his course by calling into consultation one or more of 



294 PKINCIPLES OF SUBGEKY. 

his colleagues, to protect himself against unmerited criticism in the future 
or, perchance, a suit for malpractice. An early radical operation for osteo- 
myelitis (and the author means by this an operation done as soon as a posi- 
tive diagnosis can be made, and before any external swelling has appeared) 
accomplishes the following most desirable results: 1. It removes pain. 2. 
It enables the surgeon to remove the local cause of the disease completely or 
in part. 3. It prevents extensive necrosis. 4. It is the best prophylactic 
measure against fatal septicaemia and pyaemia. 5. It prevents extensive de- 
struction of the periosteum and other contiguous soft parts. 6. It cuts short 
the attack and expedites recovery. 

As we have seen, the pain which attends osteomyelitis is caused by the 
intraosseous tension and by the secondary periostitis. If the medullary cav- 
ity is opened freely before suppurative periostitis has developed, the opera- 
tion removes the conditions which cause the pain, and will therefore accom- 
plish at once what anodynes and external applications can do but imperfectly. 
The removal of the infected tissues fulfills the etiological indications of the 
disease, the removal of the pus-microbes completely or in part, which, with 
thorough disinfection of the cavity, prevents the further extension of the 
disease. Necrosis takes place from the action of the pus-microbes and their 
toxins on the tissues, intraosseous tension, and vascular obstruction, all of 
which causes are either removed or, at least, favorably modified by an early 
radical operation. Limitation of necrosis is one of the most marked results 
of all early aseptic operations for acute osteomyelitis. Progressive sepsis is 
caused by the introduction of pus-microbes and their toxins from the osteo- 
myelitic focus into the general circulation; hence, there is no better way in 
which this fatal complication can be prevented than by the removal of the 
infected tissues and subsequent disinfection of the cavity, followed by effi- 
cient drainage and strict antiseptic treatment of the wound. As pyaemia is 
always caused by septic thrombophlebitis, no surer way of guarding against 
it could be devised than the early removal of the infected tissues, which may 
include the vessels with a beginning thrombophlebitis. If the interior of an 
osteomyelitic bone is rendered accessible to direct means of disinfection, such 
treatment will often, if not invariably, prevent the extension of the suppura- 
tive inflammation to the periosteum and surrounding connective tissue, 
which constantly occurs when the patients are treated upon the expectant 
plan. An early radical operation, by limiting the necrosis and extension of 
the inflammation to the surrounding soft tissues, shortens the attack, and is 
conducive toward establishing at an early time a reparative process in place 
of one of destruction. Pathological fractures will become less frequent com- 
plications in acute osteomyelitis as soon as early radical operations are more 
generally adopted. Early operations under aseptic precautions, in short, are 
life-saving operations; at the same time, they will leave the parts in a more 



TREATMENT. 295 

satisfactory condition for rapid and satisfactory repair. An early operation 
I should call one done before secondary suppurative periostitis has appeared. 
An intermediate operation for acute osteomyelitis is one performed after sup- 
puration has occurred around the bone first affected, and late operations are 
undertaken for the removal of necrosed bone. 

Early Operations. — The surface of the limb is prepared in the same 
manner as for other aseptic operations. The primary focus of the disease, 
usually in the vicinity of an epiphyseal line, is accurately located by search- 
ing for the tenderest point. Over this point, or as near to it as the nature 
of the soft parts will permit, an incision is made down to the bone. As the 
operation is to be done below Esmarch's constrictor, the soft tissues can be 
carefully examined during every step of the operation, and their exact con- 
dition ascertained. The skin and underlying fascia are cut through with one 
stroke of the knife, when the knife should be laid aside and the remaining 
tissues, down to the bone, are carefully separated with the finger and peri- 
osteal elevator, which can be readily done by following the intermuscular 
septa. The periosteum, even at an early stage, will be found vascular and 
easily separated from the bone. This structure is then reflected, with the 
soft tissues, on each side, and held out of the way with retractors. The bone 
is then opened with a small, round chisel. The trephine should never be 
used, as it is, to say the least, a bungling and inefficient instrument, while the 
chisel is an instrument of precision. For the first, or exploratory, opening a 
semicircular chisel should be used; in the further steps of the operation 
ordinary chisels, such as are used by carpenters, answer an excellent purpose. 
As the first opening will probably be made near an epiphyseal extremity, at 
a point where the compacta is very thin, the chiseling is attended by no diffi- 
culties. The opening is made directly toward the centre of the bone. If no 
pus has formed the osteomyelitic focus is recognized by the softness and 
great vascularity of the tissues and the escape of bloody serum. If pus is 
found it will probably appear at this time as an infiltration. The object of 
the operation is not only to open the bone, but to remove all of the infected 
tissues. The opening in the bone is, therefore, enlarged in the direction of 
the shaft to the extent of the disease in its interior. If the suppurative in- 
flammation is extensive, involving half of the bone, or, perhaps, the entire 
shaft, it is advisable to make several incisions over the bone in the same line 
instead of one large incision, thus avoiding a large wound and, perhaps, in- 
jury of important structures; at the same time the interior of the bone is 
rendered accessible to direct treatment by opening the bone at the corre- 
sponding points and scraping out the medullary tissue contained in the in- 
tervening sections with a sharp spoon, the handle of which can be bent at 
any desirable angle. After the whole cavity has been thoroughly curetted 
it is disinfected by pouring peroxide of hydrogen into it, followed by irriga- 



296 PKINCIPLES OF SUKGEKY. 

tion with a solution of corrosive sublimate (1 to 1000) or a 5-per-cent. solu- 
tion of carbolic acid, and then dried and mopped out with a 10-per-cent. solu- 
tion of chloride of zinc. The cavity is then packed with iodoform gauze, 
which is brought out of the wound or wounds to serve the purpose of a capil- 
lary drain. A copious, moist, hot antiseptic dressing is applied, and the limb 
immobilized in proper position upon a splint. A fall in the temperature, 
and other signs of improvement soon after the operation, are indications that 
the desired object, primary disinfection of the osteomyelitic focus, has been 
attained. If on the following day the temperature show no reduction, the 
dressings are removed, antiseptic irrigations are again employed, and the 
limb is dressed in the same manner as after the operation. Frequent irriga- 
tions with a 1 / 2 - to 1-per-cent. solution of acetate of aluminum, or a weak 
aqueous solution of tincture of iodine, should be made, and the limb confined 
upon a suspension splint. In 1888 Tscherning recommended very strongly 
early operative interference. He insisted that the bone should be exposed 
and opened in such a manner that the entire infected medulla could be 
scraped out. Karewski operated upon a number of young children in ac- 
cordance with this advice as early as the third day after the beginning of the 
initial symptoms, with the result that the disease was cut short and necrosis 
was prevented. 

Intermediate Operations. — If a case of acute osteomyelitis come under 
treatment after purulent infiltration has occurred around the affected bone, 
no time should be lost in evacuating the pus* by incision and drainage. 
Multiple incisions and numerous tubular drains are often required to effect 
complete evacuation and secure free drainage. In these cases operations on 
the bone itself should be limited to making small openings in the exposed 
portion of the bone for the purpose of reaching its interior with antiseptic 
irrigations. Large openings, under these circumstances, might lead to patho- 
logical fractures. The subsequent treatment is conducted on the same prin- 
ciples as a case of phlegmonous inflammation and purulent infiltration of 
the soft parts. 

As in the early treatment of osteomyelitis by radical operation, the limb 
must be supported in a desirable position by some kind of a splint. The use 
of a proper splint in the treatment of acute osteomyelitis is indispensable. A 
well-fitting posterior splint, or the anterior suspension splint of E. iKT. Smith, 
secures rest for. the limb, prevents contractures and subluxation of joints, 
and finally diminishes the frequency of pathological fractures. Catarrhal 
synovitis is treated by aspiration, and suppurative synovitis by incision, 
drainage, and antiseptic irrigations. During the acute stage of suppurative 
osteomyelitis the removal of an entire shaft of a long bone should be limited 
to one bone of the forearm or leg, as the removal of the entire shaft of the 
humerus or femur before the formation of an involucrum of sufficient firm- 



TREATMENT; 297 

oess to act as an efncienl support would greatly complicate the mechanical 
pari of the after-treatment, and the procedure might result in imperfect 
restoration of the bone removed. Where the greater portion or the entire 
shaft of a bone has become necrosed and has separated at one or both epi- 
physeal junctions, it may become necessary to remove it during the acute 
stage to avert death from exhaustion from profuse discharges and septic 
fever incident to the presence of such a large septic foreign body. It has 
been argued against such a procedure that the bone would not be regenerated 
after its removal. This fear, however, is not supported by facts, as, when 
the periosteum and the epiphyses remain, a good, if not perfect, substitute 
is reproduced. Duple}^ Holmes, McDougal, Lefort, Giraldes, Spence, Petre- 
quin, Wilms, Cheever, Hopes, and Gay have each reported cases where al- 
most complete reproduction followed the removal of the entire shaft, It is 
very important, especially in children, to preserve both epiphyses, to prevent 
subsequent shortening and other deformities of the limb. Where the con- 
tinuity of a bone has been destroyed, either by a pathological fracture or the 
removal of a part or an entire diaphysis, which has separated before the in- 
volucrum has become sufficiently firm to serve the purpose of an efficient 
mechanical support, a suitable mechanical support must be applied for a 
long time to guard against shortening and bending of the new bone. During 
the septic stage of acute osteomyelitis with suppurative synovitis amputation 
may become necessary to save the life of the patient. In exceptional cases 
the same sad alternative may become a necessity after the acute symptoms 
have subsided, for the purpose of removing the source of exhausting sup- 
purative discharges. Our present means of treating abscesses, diffuse puru- 
lent infiltrations, and suppurative diseases of joints are, fortunately, so per- 
fect and efficient that even severe cases can be treated on a more conservative 
plan, and amputation should be restricted to extreme cases as a dernier 
ressort. Should signs of pyaemia arise, our main reliance must be placed on 
the administration of large doses of quinine and alcohol. Luecke has 
obtained the best results from large doses of alcoholic stimulants. In- 
stances have been reported where two pints of cognac were given during 
twenty-four hours with decided benefit. Osteomyelitic patients should be 
surrounded by the most favorable hygienic influences, as fresh air, equable 
temperature, light, and an abundance of plain, nutritious food. As soon as 
the acute symptoms have subsided, iron, especially tinctura ferri chloridi, 
should be freely administered. If osteomyelitis is complicated by the coex- 
istence of other diseases, such as syphilis, tuberculosis, rachitis, etc., the 
treatment of the latter should receive appropriate attention. 

Late Operations. — As late operations will be considered the operative 
removal of sequestra. The operation for the removal of detached dead bone 
is called necrotomy or sequestrotomy. The operative removal of a seques- 



298 PKINCIPLES OF SURGERY. 

trum should always be postponed until complete separation has taken place 
and the involucrum is strong enough to furnish the necessary mechanical 
support. If an operation is undertaken at an earlier time, there is danger of 
unnecessarily removing a portion of healthy bone or of leaving a part of 
the sequestrum. Necrosis is not a disease, but always a result of a destructive 
inflammation. It is not always easy to determine whether separation of the 
sequestrum has taken place in a given case. The sinus leading down to the 
dead bone may be so tortuous that it is impossible to introduce a probe into 
the interior of the involucrum. Again, if the sequestrum is felt with the 
probe it is often impossible, by any kind of manipulations, to ascertain in 
this manner its mobility, as it is often firmly incased in a bed of granula- 
tions. The time required in separation of the sequestrum varies greatly: a 
whole phalanx of a finger may be separated completely in four weeks, a 
cortical sequestrum of a long bone may become detached in six weeks to two 
months, while the separation of half or an entire shaft of the large long 
bones, as the femur or humerus, may require from three to six months. If 
the patient's general health is improving there is no need of haste in the 
removal of a sequestrum, as there is nothing lost and a great deal gained 
by waiting until sufficient time has elapsed for separation to take place. 
Sequestrotomy, if properly performed, is one of the most grateful of all 
operations, as it is attended by little or no danger to life, and is usually fol- 
lowed by a favorable result. Its performance has been greatly simplified by 
the use of anaesthetics and Esmarch's constrictor. 

Since Esmarch taught us how. to obtain, by a very simple appliance, a 
bloodless condition of the limb during the operation, the surgeon can make 
the necessary dissection with the same degree of accuracy as in the dissect- 
ing-room, thus avoiding injury of important vessels and nerves, which for- 
merly occurred quite frequently even in the hands of the most accomplished 
surgeons. Before the operation the entire limb is disinfected and rendered 
bloodless by elevating, it for a few minutes, when an Esmarch constrictor 
is applied on the proximal side and some distance from the seat of operation. 
I have met, in my practice, with two cases of paralysis of the musculo-spiral 
nerve from the use of Esmarch's constrictor, which was applied about the 
middle of the arm, and, although both patients recovered perfect use of the 
limb in the course of two to four months, I have since taken the precaution 
to guard against such a perplexing accident by applying the constrictor over 
the middle of the deltoid, and over several thicknesses of a towel in order 
to protect the nerves against undue pressure. Since I have made use of these 
precautions I have had no further accidents from elastic constriction. In 
an operation for extensive necrosis of the tibia the constrictor was applied 
just above the knee, and as soon as the patient recovered consciousness it 
became evident that the constriction had resulted in paralysis of the peroneal 



IK- 1 : \tmi;\ i'. 



299 



nerve. More than four months elapsed before function was completely re- 
stored. Sime that time 1 always apply the constrictor higher up, where the 
nerves are protected by a thick cushion of muscular tissue, and have seen no 
more evil effects from elastic constriction of the lower extremity. Wherever 
it is sale to make the incision in the line of one or more fistulous openings 
this should be done, but when these are in localities where there would be 
danger of wounding important vessels, muscles, or nerves, another location 




Fig. 114.— Incision for Necrotomy of the Tibia. 



must be chosen. In operations upon the humerus the exact location of the 
musculo-spiral nerve must be remembered, and if the incision necessarily 
come close to this structure the dissection is made slowly and with the use 
of blunt instruments until the nerve is found, when it can be held out of the 
way. In operations upon the lower end of the femur, even if the fistulous 
opening should be in the popliteal space, the incision down to the bone 
should be made in the course of the intermuscular septum, on the outer or 



300 PRINCIPLES OF SURGERY. 

inner side, as the posterior surface of the femur can be made accessible from 
either side by flexing the knee and by making the incision large and by keep- 
ing close to the bone, separating the soft tissues well and keeping them out 
of the way by the use of retractors. "Where the bone is covered by thick 
layers of muscles the incision is made in the direction of the muscles, and 
at a point corresponding to an intermuscular septum. In extensive opera- 
tions for necrosis of the shaft of the tibia I now invariably employ the 
S-shaped incision, as it affords more room and can be sutured with less dif- 
ficulty than a straight incision. The external incision should always be 
large, so as to afford plenty of space. As soon as the intermuscular septum 
is reached the scalpel should be laid aside and the parts carefully separated 
down to the bone by using the fingers or blunt instruments. When the bone 
is reached the periosteum is incised and reflected with the soft tissues at- 
tached to it. The opening of the involucrum is done with the chisel. In 
old-standing cases the involucrum is as dense as ivory and the chiseling is 
an exceedingly slow and laborious process, as only very small chips can be 
removed with each cut of the chisel. The brittleness of the new bone should 
warn the surgeon to chisel with care, as otherwise a fracture might result. If 
the chiseling is done at the site of a former opening, this opening is enlarged 
until the sequestrum is reached and can be extracted. Extraction of the 
sequestrum was the sole object of operations in the past; hence the dead 
bone was removed through a comparatively small opening in the bone, either 
in toto or after fragmentation. Modern surgery not only seeks to remove the 
dead bone, but to place the cavity in the best possible condition for rapid 
healing. The first indication to be fulfilled in securing a favorable repara- 
tive process after the operation is to obtain an aseptic condition of the cavity. 
This can only be done by exposing the interior of the entire cavity. Chiseling 
is continued until both ends of the cavity are reached, when the sequestrum 
can be lifted out and the granulations lining the cavity are scraped out with 
a sharp spoon. Sharp spoons of different sizes should be at hand, as the 
interior of such cavities usually presents depressions and sinuses which 
can only be dealt with successfully by the use of different-sized spoons. 
After the mechanical removal of the infected tissues the cavity is washed out 
with peroxide of hydrogen, followed by a solution of corrosive sublimate (1 
to 1000) or a 5-per-cent. solution of carbolic acid, and rubbed out and dried 
with an aseptic sponge. It is evident that the healing of such a cavity, by 
unaided resources of Nature, would be a slow process. Various attempts 
have been made to overcome the difficulties in the healing of cavities with 
unyielding walls. D. J. Hamilton has suggested sponge-grafting. Neuber 
made flaps of the skin from each side, which he fastened to the floor of the 
cavity with sutures or bone-nails (Figs. 116 and 117). Schede utilized the 
blood, which he allowed to accumulate in the cavity after suturing the ex- 



ii;i: \t\ik\t. 



301 



ternal parts, and obtained some excelleni results with this treatment. If the 
cavity is large the writer always renders it shallow by chiseling away the mar- 
gins and after disinfection sutures skin and periosteum over it, making, of 
course, provision for drainage; but he makes no attempt to bring the soft 
tissues in contact with the bone until the wound is healed, when this object 
is readily accomplished by carefully applied elastic pressure made by dress- 
ing ami bandage. E. Halm advised the detaching of the skin on each side 
to within an inch, at the posterior surface of the limb, for the purpose of 




Fig. 115.— Bone-cavity after Removal of Sequestrum and Granulations 
Necrosis of the Tibia. (After Esmarch.) 



better mobilization of the flaps, which are to be united over the centre of 
the gutter by suturing. For a number of years the author has been experi- 
menting on animals with decalcified bone in the healing of aseptic bone- 
cavities, and the experimental as well as the clinical results obtained so far 
have exceeded all expectations. The decalcified bone-chips are preserved in 
an alcoholic solution of corrosive sublimate (1 to 500) or a solution of iodo- 
form in sulphuric ether. The most essential condition for success, in the 
treatment of bone-defects by implantation of decalcified bone, is a perfectly- 
aseptic condition of the tissue to be brought in contact with the implanted 



302 PRINCIPLES OF SURGERY. 

bone. This condition is easily procured in operations on bones for lesions 
other than those caused by infection with pus-microbes, such as tumors, 
echinococcous cysts, and tubercular and syphilitic affections uncomplicated 
by suppuration. In the surgical treatment of these affections, after the re- 
moval of the diseased tissue the seat of operation must be aseptic, if the ordi- 
nary precautions in the prevention of infection from without have been ob- 
served. In such cases speedy healing of the external wound and the early 
partial or complete reproduction of the lost bone are assured. The next 
most favorable cases for this procedure are circumscribed osteomyelitic proc- 
esses in the epiphyseal extremities of the long bones, as we observe them in 
cases of primary circumscribed epiphyseal osteomyelitis, or in the form of a 
recurring attack in the same place, perhaps years after a diffuse osteomyelitis 
of the entire shaft. This method of treating bone-cavities is also applicable 
after operations for necrosis resulting from a previous attack of acute sup- 
purative osteomyelitis. The cavity must be prepared for the implantation 
of decalcified bone in the manner described above. The implantation is 
made before the removal of the constrictor, in order that, after this is done, 




Fig. 116. Fig. 

Fig. 116.— Inversion of Soft Tissues on Each Side into the Bone-cavity. (After Neuier.) 
Fig. 117. — Healing of Bone-cavity. (After Neuber.) 

sufficient blood will escape to fill the spaces between the chips, and thus serve 
the useful purpose of a temporary cement-substance. After the cavity has 
been dusted over lightly with iodoform, the chips, which have been washed 
previously in an antiseptic solution, are dried upon a gauze compress, and are 
then poured into the cavity until this is packed with them as far as the 
periosteum. The first advantage derived from this method of bone-packing 
is that the chips serve as an antiseptic tampon which arrests the free oozing 
from the surface of the bone, which always takes place after the removal of 
the constrictor. Some blood escapes between the bone-chips and coagulates 
at once, thus forming a desirable and useful cement-substance which per- 
meates the entire packing, and temporarily glues, as it were, the chips to- 
gether and the entire mass to the surrounding tissues. The periosteum 
should be carefully preserved in exposing the bone, and, after implantation, 
is sutured over the surface of the bone-chips with absorbable, aseptic, buried 
sutures. If the bone is deeply located, it may become necessary to apply a 
second and third row of buried sutures in bringing into accurate apposition 
other soft parts. The skin is finally sutured with silk. It is of the greatest 



TBBATMENT. 'M)'.\ 

importance to secure accurate apposition of the divided soft parts, in order 
to preserve for the subjacent hone all of its natural coverings. In some in- 
stances it would be, undoubtedly, superfluous to secure any form of drainage, 
as, when the cavity is perfectly aseptic and haemorrhage is not in excess of 
requirements, healing of the entire wound would be accomplished under 
one dressing. Experience, however, has taught me that tension arising from 
extravasation of blood often exerts an injurious influence upon the process 
of healing, and should be carefully avoided. As it is desirable to heal as 
much of the wound as possible without interfering with drainage, an absorb- 
able capillary drain should be inserted in the lower angle of the wound. A 
string of catgut twisted into a small cord answers an admirable purpose. The 
wound is covered with a strip of aseptic protective silk, over which a few 
layers of iodoform gauze are applied. Over this a cushion of sterile gauze 
is placed, with a thick layer of salicylated cotton along its margins for the 
purpose of guarding more securely against the entrance of unfiltered air. 
The whole of the dressing is retained by a circular gauze bandage, evenly 
and smoothly applied. For the purpose of securing absolute rest for the limb 
it is placed upon a posterior splint and kept in a slightly-elevated position. 
If no indications arise the first dressing is not removed for two weeks, when 
the entire wound will usually be found healed except a few granulations at 
the place where the catgut drain was inserted. A smaller antiseptic com- 
press is applied and the limb dressed in a similar manner. It is prudent to 
enforce rest, — not only till the external wound has healed, but until the proc- 
ess of repair in the interior of the bone has- been completed, which embraces 
a period varying from four weeks to three months, according to the size of 
the cavity and the age of the patient. If an operation for necrosis with im- 
plantation of decalcified antiseptic bone-chips is followed by suppuration, it 
is an evidence that asepsis was imperfect, and such cases must be treated 
upon the same principles as suppuration in other localities. If suppuration 
take place soon after the operation, and is profuse, it is probable that all of 
the bone-chips will have to be removed in order to facilitate the disinfection 
of the cavity. If it develop after granulation-tissue has had time to form, 
and the discharge of pus is moderate in quantity, the prospects are that the 
bone will remain and serve its purpose as a nidus for the granulation-tissue. 
In such cases an antiseptic irrigation should be made every three or four 
days until suppuration has ceased. If the bone-chips are lost by suppuration, 
or have to be removed for the purpose of a more thorough disinfection of 
the cavity, no attempt should be made at reimplantation until suppuration 
has been arrested; or, in other words, until the cavity has become lined with 
granulations and is in a comparatively aseptic condition (when the time for 
secondary implantation has arrived). After the cavity has been irrigated 
with a strong antiseptic solution the superficial granulations are removed 



304 



PRINCIPLES OF SURGERY. 



with a sharp spoon, and it is packed with bone-chips, which are implanted 
in the same manner as in the treatment of a recent cavity. 

Complete closure of the external wound under these circumstances is 
seldom obtainable, and the surface of the exposed portion of the cavity 
should be provided with a thin layer of Schede's moist blood-clot. I have 
resorted to implantation of decalcified antiseptic bone-chips in the treatment 
of bone-cavities, after necrotomy and operations for tuberculosis of bone, in 
a great many cases, and have had the satisfaction of healing large defects 
without a drop of pus under one or two dressings in from two to four weeks. 
Only in a small percentage of the cases was it found necessary to remove the 




Fig. 118. — Osteoplastic Necrotomy. (After Bier.) 



packing, and in most of these secondary implantation proved successful. 
Schede's blood-clot does not possess any antiseptic properties, like the bone- 
chips, and is not as permanent a structure. Operations by Neuber's method 
are often followed by necrosis of the flaps, and even if successful the lost bone 
is not restored. Implantation of absorbable decalcified antiseptic bone-chips, 
in the treatment of aseptic bone-cavities, is preferable to the use of viable 
grafts, as the substance used is not only absolutely aseptic, but possesses also 
valuable antiseptic properties, which must be looked upon as a valuable and 
very important quality in the treatment of such cases. Eeproduction of bone 
follows almost to perfection in every case where antisepsis proves successful; 



CllUONU' CIRCUMSCRIBED SI PP1 RATIVE OSTEOMYELITIS. 



305 



hence they serve the same purpose as viable grafts, as far as the restoration 
of lost tissue is concerned. I have chiseled a wide gutter in the humerus 
and tibia, almost from one epiphysis to the other, for the removal of large 
sequestra, and have seen such enormous defects restored, in a few weeks, 
after implantation with bone-chips. The contour of the bone is restored to 
such perfection that after a few months it would be difficult to tell where the 
operation was performed. The bone-chips serve as a temporary scaffolding 
for the granulations springing from all sides of the bone-cavity, and as they 
are removed by absorption their place is occupied by living permanent tissue; 
first by embryonal cells, which are later converted into bone. 

Bier devised an osteoplastic operation for the removal of sequestra from 
superficial bones like the tibia. The incisions down to the bone are made in 
the usual manner. The two transverse cuts through the involucrum are 







)1) 



\ 



Fig. 119. — Shulten's Method of Necrotomy. 

made with a key-hole saw and the longitudinal section with the chisel. With 
an elevator the bone is raised, with the overlying soft tissues, like the lid of 
a box, thus freely exposing the interior of the involucrum. After the re- 
moval of the dead bone and granulations the flap is replaced and sutured. 
This operation is unnecessarily severe, difficult, and tedious, and the disad- 
vantages more than overbalance its advantages. 

With a view of closing the bone-cavity (especially in operations upon 
the tibia) Schulten mobilizes the two opposite walls and inverts them with 
the attached overlying skin and sutures them as shown in Fig. 119. In 
favorable cases this operation yields excellent results. 



CHRONIC CIRCUMSCRIBED SUPPURATIVE OSTEOMYELITIS. 

This is the bone-abscess of the older authors. The etiology of this form 
of suppurative inflammation is the same as in the diffuse variety. Clinically, 



306 PKIXCIPLES OF STJEGERY. 

two kinds can be distinguished: 1. Primary epiphyseal circumscribed osteo- 
myelitis. 2. Secondary circumscribed osteomyelitis. The first kind is occa- 
sionally met with as a multiple affection, and is then attended by more or 
less constitutional disturbances and may result in epiphyseolysis. The sec- 
ondary form occurs in bones that have been the seat of an attack of diffuse 
suppurative osteomyelitis, the patient apparently having recovered com- 
pletely from the primary attack years before. It is still a question under dis- 
cussion if in these cases the infection is caused by microbes which have re- 
mained in the tissues in a latent state since the primary attack or whether it 
is caused by localization of pus-microbes in the tissues weakened by the first 
attack. Eosenbach is of the opinion that recurring attacks of osteomyelitis 
in the same bone are caused by pus-microbes which have remained in the 
tissues, and which again become pathogenic when the tissues around them 
are rendered susceptible to their action by subsequent causes. I am strongly 
inclined to the same opinion. I have seen numerous cases where, in per- 
sons from 16 to 25 }'ears of age, repeated attacks of circumscribed osteomye- 
litis occurred in a bone which, during childhood, had passed through an at- 
tack of acute osteomyelitis. The tibia, femur, and humerus are the bones 
which are most frequenthy attacked by recurrent osteomyelitis. The sec- 
ondary attacks occur either in the centre of the sclerosed bone, the former 
site of the infected medullary cavity, or near one of the epiphyseal lines. I 
have no doubt that secondary osteomyelitis will be of less frequent occur- 
rence after early operations for osteomyelitis, and that antiseptic seques- 
trotomy will be more generally practiced. 

Symptoms. — The most important symptoms of circumscribed central 
suppuration in bone are pain and tenderness. The pain is deep-seated, in- 
tense, of a boring or gnawing character, and is generally more severe after 
active exercise and during the night. It is often intermittent, and has fre- 
quently been wrongly interpreted as neuralgia of bone. 

The tenderness is circumscribed, and corresponds to the location of the 
suppurating focus. It is due to a circumscribed secondary plastic periostitis. 
The external swelling is slight, and often completely wanting. Usually 
neither redness nor oedema is present. 

In the diagnosis of circumscribed osteomyelitis it is important to re- 
member gummatous or syphilitic osteomyelitis. The latter affection is not 
rare during the late stage of syphilis. It attacks the shaft as well as the 
epiphyseal extremities. Like osteomyelitis, gumma of the shaft of a bone 
may appear as a periosteal, cortical, or central lesion. The central variety 
may be circumscribed or diffuse. The gummatous process may extend from 
the cortex to the medullary canal and vice versa. In gummatous osteomye- 
litis softening takes place in the centre of the swelling and hypertrophy and 
sclerosis in the periphery. In the differential diagnosis between circum- 




Fig. 120. — Central Syphilitic Osteomyelitis of the Lower End of the Femur. 




Fig. 121.— Cortical Syphilitic Osteomyelitis of the Femur. (Frank Billing*.) 



CHKONIC CIRCUMSCRIBED SUPPURATIVE OSTEOMYELITIS. 307 

scribed and gummatous osteomyelitis it becomes necessary to study carefully 
the clinical history and to make search for syphilitic affections in other parts 
of the body. 

Pathological Anatomy. — Limited suppurative osteomyelitis gives rise to 
a circumscribed abscess, which varies in size from a pea to a walnut. Xeerosis 
of bone seldom takes place; if it does, the sequestra are small and composed 
exclusively of cancellated tissue. If the abscess is situated in an epiphysis 
it may open into the adjacent joint and become the cause of a secondary sup- 
purative arthritis. Thrombophlebitis, sepsis, and pyamiia rarely occur. The 
periostitis which attends chronic suppuration in bone always assumes a plas- 
tic type, as the periosteum is beyond the reach of pus-microbes. Epiphyseal 
osteomyelitis is often associated with chondritis and osteoporosis: conditions 
which may result in pathological fracture. If in this form of osteomyelitis 




Fig. 122. — Gumma. Round and spindle-shaped nuclei imbedded in a granular and 
fibrillated matrix containing many multinucleated giant cells with granular protoplasm. 
X 200. 

the sirppuration extend to the periosteum, a circumscribed suppurative peri- 
ostitis occurs, which is followed by the formation of small abscesses in the 
epiphyseal region. Limited necrosis in these cases is of frequent occurrence. 
Treatment. — Circumscribed osteomyelitic processes in the epiphyseal 
extremities of the long bones, as we observe them in cases of primary cir- 
cumscribed suppuration in the epiphyseal region, or in the form of a recur- 
ring attack in the same place or in the sclerosed shaft, perhaps years after a 
diffuse osteomyelitis of the entire shaft, are favorable cases for implantation 
of decalcified antiseptic bone-chips, as an aseptic condition of the cavity can 
be readily procured after the operative removal of the infected tissues. The 
inflammatory focus can be located externally with accuracy by the presence 
of a circumscribed area of tenderness, and the centre of the tender spot con- 
stitutes the guide in the search for the abscess. The operation is performed 



308 PRINCIPLES OF SUEGEEY. 

under strict aseptic precautions, and by the bloodless method. The chiseling 
is done in the direction of the centre of the bone by making a track perhaps 
an inch square. If the abscess is not found at a certain depth, the surround- 
ing tissue is explored with a small drill in different directions from the track, 
until it is discovered, when further excavation is again made with the chisel. 
As soon as the abscess has been fully exposed the pus is washed out and the 
size of the cavity ascertained by probing. As the abscess is often surrounded 
by a zone of tissue infiltrated with pus, all of the infected tissues are scraped 
out thoroughly with a sharp spoon, after which the cavity is prepared for 
the implantation of the bone-chips in the same manner as in operations for 
necrosis. Iodoformization of the cavity and the implantation of antiseptic 
bone-chips are measures which are well calculated to resist the pathogenic 
action of pus-microbes which might still remain, and in the majority of 
cases will secure an aseptic healing of the wound. I have repeatedly seen 
cavities the size of a small orange, in the head of the tibia, heal under two 
dressings by this method, with perfect restoration of the bone removed. The 
mechanical means resorted to to obtain an aseptic condition of the cavity 
will often result in increase to twice its original size, but the loss of tissue is 
not to be taken into consideration when a method of treatment is to be em- 
ployed which requires perfect asepsis in order to be successful in placing the 
parts in a condition where perfect restoration will be accomplished with 
almost unfailing certainty. 



CHAPTER XIII. 

Suppuration in Large Cavities; Abscess of Internal Organs. 

The suppurative affections of the different large cavities in the body 
present so many features common to all of them that they will be con- 
sidered together in this chapter. Suppurative inflammation of a mem- 
brane, synovial or serous, lining a closed cavity, is characterized by the 
rapidity with which the inflammatory process spreads over the entire sur- 
face, and the retention of the products of inflammation in a preformed 
closed space. Abscesses of internal organs result from infection by the 
extension of a suppurative lesion from the surface along the course of 
blood-vesels, lymphatics, nerve-sheaths, or by the localization of pus- 
microbes floating in the blood in a locus minoris resistentice of an organ. 

SUPPURATIVE ARTHRITIS. 

Suppurative inflammation in an intact joint is always caused by 
localization of pus-microbes in the synovial membrane, conveyed to this 
structure by the blood, which results in suppurative synovitis, and, by the 
extension of the infection to the other structures of the joint, is often 
followed by complete disorganization of the joint (panarthritis). In this 
manner metastatic suppurative synovitis is caused, as it occurs, in pyaemia, 
gonorrhoea, and in some of the general infective diseases. 

Bacteriological Researches. — In animals susceptible to the action of 
pus-microbes, the injection into a joint of a pure culture is usually fol- 
lowed by acute suppuration, and, not infrequently, by the formation of 
extensive paraarticular abscesses. Hoffa, Kranzfeld, and Krause have 
studied, with special care, the microbic origin of suppurative synovitis, 
and all of them found in the pus one or more varieties of the microbe of 
suppuration. Krause found, in the pus of suppurating joints in small chil- 
dren, a streptococcus the identity of which with the one described by 
Eosenbach was proved by cultivation experiments. In one case the same 
microbe was also found in the products of a purulent meningitis, which 
followed in the course of the joint disease. 

The pneumococcus has been repeatedly found as the only microbic 
cause of suppurative inflammation of joints. Tournice and Courmont re- 
port such a case. The patient was 50 years of age, the subject of second- 
ary syphilis and pneumonia; during the course of the latter disease an 
arthritis developed on the sixth day. Other serous surfaces became in- 
volved, and the patient died. They conclude from this and other cases 

(309) 



310 PRINCIPLES OF SURGERY. 

that arthritis due to infection with pneumococci differ widely in the in- 
tensity of the inflammation from a simple serous effusion to complete dis- 
organization of the joint. The pneumococci are always found in the pus 
of the affected joints. 

Yogelius reports two cases of croupous pneumonia complicated by 
suppurative arthritis, in which the pneumococci were found in the joint 
effusion. He also collected 11 similar cases from the current literature. 
In the majority of cases this complication made its appearance during the 
first five days, but in 1 not until the eleventh day. The joint effusion was 
purulent in 6 cases, sero-purulent in 2, and sero-fibrinous in 1. In the 
remaining 2 the nature of the inflammatory product is not mentioned. 




Fig. 123. — Bacillus Typhosus. Twenty-four-Hour Culture on Agar-agar. 

Another microbe which has been isolated from suppurating joints as 
the only microbic cause of the inflammation is the bacillus of typhoid 
fever. Eobin and Serrede have studied the forms of typhoid fever compli- 
cated by inflammation of joints, as well as grave joint affections accom- 
panied by typhoid symptoms. They distinguish the following groups of 
cases: 1. Those in which the onset is marked by acute swelling and pain 
in the joints, but in which the subsequent clinical course revealed typhoid 
fever. These cases they call arthro-typhoid, analogous to pneumo- 
typhoid. 2. Cases of typhoid in which the arthritis always terminates in 
suppuration and is due to infection with the typhoid bacillus. 3. Septic 
disease of joints in which the typhoid condition is due to septic intoxica- 
tion. 



SUPPURATIVE A Kin in lis. 311 

Meunier reports a case in which the pneumococcus and streptococcus 
were found at the same time in the pus removed by aspiration from a sup- 
purating joint. Bernarheig collected 10 cases of articular complications 
in diphtheria. The larger joints are usually affected. The joint disease 
developed from the seventh to the fifteenth day after the onset of diph- 
theria. In the severe cases the joints suppurated, the suppuration being 
caused by a secondary mixed infection with the streptococcus pyogenes. 
The milder forms of joint disease they attributed to the toxins of the diph- 
theria bacillus. 

The same streptococcus was found by Huber and Bahrdt in pus from 
a suppurating joint, and in the diphtheritic membranes of a scarlet-fever 




Fig. 124. — Micrococcus Gonorrhoeae. From male urethra seven days after exposure 
to infection. Leucocytes and two urethral lining cells are shown. (Stained with Loeff- 
ler's methylene-blue.) 

patient. The so-called gonorrhceal rheumatism is a suppurative synovitis, 
but opinions are divided in reference to the pyogenic properties of the 
gonococcus. The microbe was discovered in gonorrhceal pus by Neisser, 
in 1879. Its direct etiological relation to gonorrhoea has been sufficiently 
demonstrated by experimental research and clinical observation. The 
gonococcus always occurs in pairs, and is, therefore, a diplococcus. 

The cocci appear as hemispherical bodies, with their flattened surfaces 
in apposition, which imparts to the microbe the characteristic biscuit- 
shaped appearance. They are found in clusters upon, or, what is more 
probable, as Bumm asserts, within the pus-corpuscles of gonorrhceal pus. 
Their intracellular location was shown by Bumm, by examining pus- 
corpuscles in water; when, after imbibition of fluid, the cells become 



312 PRINCIPLES OF SURGERY. 

swollen, the cocci could be seen between the molecular grannies of the 
protoplasm. The microbes within the corpuscles may become so numerous 
as to fill the entire space, with the exception of the nucleus. It can be 
cultivated upon solidified blood-serum or agar-agar meat-peptone. Its 
pus-producing property in specific inflammation of the mucous membrane 
of the urinary organs and conjunctiva is well known, and at present is 
not attributed to its direct effect on the tissues, but to the action of the 
toxins which it produces. Many cases have been reported which appear 
to show that under certain circumstances the microbe enters the circula- 
tion and becomes the cause of metastatic suppuration, especially in joints. 
Schwarz asserts that the gonococcus is constantly found in the effusion 
of joints in gonorrheal rheumatism, in other abscesses caused by gonor- 
rhoea, and in the glands of Bartholin, in women who have passed through 
an attack of gonorrhoea. Petrone detected the gonococcus in the effusion 
of joints and in the blood, in two patients suffering from gonorrhoeal 
rheumatism. He regards the joint-complications as metastatic processes 



■• W$) fe^# m m <^> •* •! 






Fig. 125. — Gonococcus. A, from a pure culture. B, from a blennorrhceic con- 
junctival secretion; an epithelial cell covered with cocci; a pus-corpuscle with cocci 
in the protoplasm; a pus-corpuscle completely filled with cocci; a free mass of cocci in 
close proximity to a pus-corpuscle. C, development of gonococci. (Bumm.) 

caused by the gonorrhoeal infection. Other authors found metastatic 
abscesses in gonorrhoeal patients, cultivated from the pus-microbes of sup- 
puration, and on this account regard them as the result of a secondary or 
mixed infection. If gonococci can transform epithelial cells of the urethra 
or conjunctiva into pus-corpuscles, there is no reason to doubt that under 
favorable circumstances they can exercise the same pathogenic effect on 
other tissues, particularly the synovial membrane of joints. The pyogenic 
properties of gonococci in other localities than the mucous membrane 
of the urinary tract can no longer be doubted. It has been found as the 
only microbic cause in fatal cases of endocarditis and in the pus of ab- 
scesses in different parts of the body. In joints it may produce a meta- 
static inflammation which results in a fibrinoplastic, serous, or purulent 
product, according to the intensity of the infection or the receptivity of the 
patient to the pathogenic action of this microbe. 

Symptoms and Diagnosis. — Suppurative arthritis is usually attended 
by a great deal of pain. This symptom is a prominent one in this affec- 




SUPPURATIVE ARTHRITIS. 313 

tion on account of the intensity of the inflammation, and also because 
the pus accumulates with great rapidity in the joint, causing tension. Noc- 
turnal exacerbations are common. The pain is greatly aggravated by pass- 
ive motion, and any attempt on the part of the patient to use the joint 
vastly increases the suffering. Flexion of the joint is an early symptom, 
and increases in degree with the progress of the disease. In suppurative 
inflammation of the hip- and knee- joints it is not uncommon to find the 
limb fixed at right angles. In advanced cases of suppurative gonitis the 
tibia becomes partially dislocated backward and rotated outward. The 
swelling, as long as it is caused by the effusion into the joint, is propor- 
tionate to the amount of fluid contained in the joint. In the knee-joint 
the patella is raised from the condyles of the femur, the depressions on 
each side of it are effaced, and the upper recesses of the synovial sac be- 
come prominent. After perforation of the capsule the pus escapes into 
the loose paraarticular connective tissue, where it causes a rapidly-spreading 
phlegmonous inflammation. In very acute cases rupture of the capsule 
and an extensive paraarticular abscess may appear in less than a week. 
With the rupture of the capsule of the joint the pain is diminished, but 
the general symptoms are aggravated. The parts around a suppurating 
joint usually present an cedematous appearance. The clinical history is 
often of great value in arriving at a conclusion in reference to the char- 
acter of the synovitis. If an arthritis develop insidiously in connection 
with a suppurating lesion, attended by grave general symptoms, it is an 
evidence which renders a diagnosis of pyaemia more than probable. In 
pyaemia the joint affections appear often, either simultaneously or in 
rapid succession, as multiple affections. An obstinate joint affection, ap- 
pearing in the course of an attack of gonorrhoea, is generally either a sero- 
purulent or suppurative synovitis. Gonorrhoeal synovitis develops most 
frequently from the second to the fourth week after the appearance of the 
primary disease. If any doubt exist as to the character of the effusion 
into a joint, this can be readily dispelled by making an exploratory puncture 
with an ordinary hypodermic needle. 

Treatment. — The only form of suppurative synovitis amenable to any 
other treatment, short of free incision, drainage, and antiseptic irrigation, is 
the sero-purulent effusion complicating gonorrhoea. In such cases the treat- 
ment by aspiration, irrigation with a 3-per-cent. solution of carbolic acid, fol- 
lowed by compression of the joint and fixation of the limb in an immovable 
dressing, is usually successful in permanently removing the effusion. In 
gonorrhoeal joints and in joints the seat of secondary infection in pyaemic 
patients I have obtained very satisfactory results from repeated tapping 
followed by injection with a 5-per-cent. solution of carbolic acid. The ab- 
sorption of the products of inflammation and return of function are has- 



314 PRINCIPLES OF SURGERY. 

tened by massage and hot and cold douches. If a joint contain pus, tem- 
porizing measures should be abandoned, and the pus should be evacuated 
either by aspiration followed by washing out with an antiseptic solution, 
which should be repeated until the fluid returns clear, or, what is prefer- 
able in the vast majority of cases, the joint is treated from the beginning 
as an ordinary abscess. For irrigation of a suppurating joint after in- 
cision, a V 2 -per-cent. (0-5 per cent.) solution of acetate of aluminum 
should be used. If the aspirator is used for evacuation and intraarticular 
medication, the greatest care must be exercised not to inject atmospheric 
air into the joint, as. aside from the danger of increasing the affection 
by the admission of air, such accidents have been followed by immediate 
death from air-embolism. The most efficient treatment in cases of sup- 
purative arthritis is incision and drainage under strictest aseptic precau- 
tions. As in the treatment of acute abscesses, the incisions must be made 
in places where drainage is most required. A long pair of haemostatic 
forceps is an indispensable instrument in draining a joint. In draining 
the knee-joint three transverse tubular drains should be inserted: one 
beneath the tendon of the patella, one under the patella, and one across 
the upper recess of the joint. The fourth drain should be passed directly 
through the joint between the condyles of the femur, reaching from one 
side of the patella into the popliteal space. This would require eight in- 
cisions, each from 1 / 2 to 1 inch in length: half of them serve as openings 
into the joint for the forceps, while in making the remaining incisions only 
the skin and fascia are cut to the requisite extent over the point of the for- 
ceps. In tunneling the soft tissues in the popliteal space, with the forceps, 
from within outward, the opening is to be made to one side of the large 
vessels and nerves. Such an operation requires the administration of an 
anaesthetic and the use of elastic constriction of the limb. 

As soon as all the drains are inserted the joint is washed out in dif- 
ferent directions with one of the stronger antiseptic solutions, after which 
a copious antiseptic dressing is applied and the limb is immobilized upon a 
splint. If on the following day the fever has not subsided, or as soon as 
the dressing has become saturated with the discharges, it is removed 
and the irrigation repeated as before. As soon as suppuration diminishes, 
through drainage is dispensed with and the drains are shortened from time 
to time, to be entirely removed with the disappearance of the swelling 
and the cessation of suppuration. The elbow-joint can be efficiently 
drained by passing a drain transversely through the joint, between the ar- 
ticular surfaces of the humerus, radius, and ulna. In draining the ankle- 
joint a small incision is made down into the joint, at a point corresponding to 
the anterior margin of the external malleolus, through which a haemo- 
static forceps is introduced and pushed in a backward direction, along the 



ENDOCRANIAL SUPPURA PION. 315 

upper surface of the astragalus, until its point ran be felt posteriorly under 

the skin, to the outer side of the tendo Achillis. The skin is then incised, 
the opening enlarged by unlocking the forceps and separating its blades, 
and a fenestrated rubber drain drawn through. If, as it so often happens, 
the posterior portion of the capsule of the joint bulge considerably, this 
can be drained by a drain inserted transversely underneath the Achilles 
tendon near its attachment to the os calcis. Through drainage of the 
shoulder-joint in an anteroposterior direction can be established in the 
same manner without much difficulty. Drainage of the hip-joint is always 
difficult and never efficient. The best plan to follow is to open the joint 
from behind through an incision three or four inches in length, and then 
to pass a long pair of Pean's or polypus forceps between the capsule and 
the neck of the femur, either along the upper or lower border, in the di- 
rection of the groin, and to make a counter-incision upon the point of the 
instrument, and to draw a tubular drain through the Vhole length of the 
track. The wrist-joint can be drained transversely and antero-posteriorly, 
without fear of injuring any important structures. If suppuration con- 
tinue, in spite of free drainage and careful antiseptic after-treatment, 
threatening the life of the patient from exhaustion or sepsis, more ag- 
gressive measures are indicated. Under such circumstances, it becomes 
often an exceedingly difficult matter to decide which one of the operative 
procedures should be adopted: arthrectomy, excision, or amputation. If 
the patient's strength is so much reduced that arthrectomy or excision 
offer no prospects of a successful issue, amputation should be performed. 
This alternative becomes an unavoidable necessity if the suppurative ar- 
thritis is complicated by extensive burrowing of pus among the muscles, 
tendons, and paraarticular tissues. If the patient's strength warrant an 
arthrectomy, this operation should be done if the disease is limited to the 
synovial membrane of the joint. Typical or atypical resection is to be 
restricted to cases where the articular cartilages and bone itself are found 
diseased. In resection of joints for suppurative affections, the surgeon 
must aim to remove only infected tissues; hence incomplete atypical are 
more frequently indicated than complete, or typical, resections. All cases 
of suppurative inflammation of joints should be treated from the be- 
ginning by immobilization of the limb and by the use of an appropriate 
mechanical support, both for the purpose of securing rest and to prevent 
deformities. 

EXDOCRAXIAL SUPPURATION. 

(a) Suppurative Pachymeningitis. — Suppurative inflammation of the 
dura mater occurs either as a circumscribed or diffuse affection. It is 
caused by direct or indirect infection with pus-microbes. Direct infection 



316 PKIXCIPLES OF SURGERY. 

occurs when the membrane is in communication with an infected pene- 
trating wound of the skull. Traumatism, without infection, never results 
in suppurative inflammation of the envelopes of the brain; nor does the 
presence of an aseptic foreign body produce it. Aseptic injuries of the 
brain and its envelopes are productive of circumscribed, degenerative, or 
plastic lesions, but no suppuration. Septic inflammation of the meninges, 
on the other hand, is noted for its tendency to become diffuse and to 
extend from one tissue to another, both by continuity and contiguity. 
Thus, in cases of pachymeningitis with loss of continuity of the dura 
mater, in cases of compound fractures of the skull, resulting from infec- 
tion with pus-microbes from without, the inflammation commences upon 
the outer surface of the membrane, and if the pus-microbes do not pene- 
trate the tissues the suppurative process remains superficial; but, as is 
more frequently the case, the microbes wander deeper into the tissues, 
until the entire thickness of the dura has become infected, and when the 
inner surface is reached, the underlying membranes, the arachnoid and 
pia mater, as well as the surface of the brain itself, are liable to become 
involved, step by step, by the extension of the infection from membrane 
to membrane and surface to surface. Suppurative pachymeningitis may 
remain as a circumscribed affection, and, if the internal surface of the 
dura is the seat of suppuration, it results in the formation of a subdural 
abscess. In circumscribed subdural suppuration the diffusion of the pus 
between the dura mater and the arachnoid is prevented by a plastic exuda- 
tion, which' cements the two membranes together. In suppurative pachy- 
meningitis, affecting only the outer surface of the dura, we often find a 
subcranial abscess, the outer wall of which is formed by the skull and the 
inner by the dura mater. The mechanical effect of the presence of pus in 
either locality will give rise to the same group of cerebral symptoms. In- 
direct infection of the dura mater with pus-microbes occurs in cases of 
suppuration in the epicranial tissues and in suppurative osteomyelitis of 
the cranial bones, by extension of the infection along the course of blood- 
vessels. In this way an insignificant peripheral suppurative lesion of the 
coverings of the skull is often followed by a grave form of endocranial 
suppuration. 

Symptoms and Diagnosis. — Diffuse septic pachymeningitis is always 
attended by inflammation of the arachnoid, pia mater, and cortex of the 
brain, and the symptoms point more toward a cortical encephalitis than 
a pachymeningitis. Localized suppurative pachymeningitis gives rise to 
symptoms which indicate the presence of a phlegmonous inflammation, 
modified in this instance by symptoms arising from mechanical disturb- 
ances, caused by the presence of inflammatory exudation, or the partici- 
pation of the surface of the brain in the suppurative process. In the acute 



ENDOCKANIAL SUPPUB \ DION. 317 

septic form, following a compound fracture of the skull, the first symp- 
toms are observed, usually, during the second or third day after the in- 
jury, and rapidly increase in intensity from the progressive extension of 
the infection. In the circumscribed form the symptoms are more localized. 
The headache is often severe, especially if the inflammation is located 
upon the inner surface of an intact dura, and involves a corresponding 
extent of the subjacent membranes and cortex of the brain. The early 
symptoms are those of irritation, to be followed, as the accumulation of 
pus increases, by evidences of compression. By means of focal symptoms, 
it is often possible to locate the seat of the inflammatory product in the 
interior of an intact skull with sufficient accuracy to enable the surgeon 
to evacuate the pus by operative measures. Acute suppuration between 
the surface of the brain and the inner surface of the skull is always at- 
tended by a rise in the temperature. The pulse is accelerated, at first full 
and bounding, to become slower and slower as compression increases. If 
the pulse, in a case of endocranial inflammation, has been gradually re- 
duced from 120 to 35 or 40, it is a sign that cerebral compression has 
reached the maximum extent compatible with life, and when it again 
reaches its former frequency it is an indication that dissolution is near at 
hand. The condition of the dura mater in subdural suppuration is of great 
importance in determining the presence or absence of accumulation of pus. 
In compound fractures, with loss of bone-substance, the existence of a sub- 
dural abscess is indicated by bulging of the dura into the opening of the 
skull and absence of cerebral pulsations. In trephining the skull for a 
supposed endocranial abscess, the surgeon's duty is to explore the sub- 
dural space, or to incise the dura mater, if this membrane appear tense or 
bulge into the opening, and if cerebral pulsations cannot be seen or felt. 

Treatment. — The successful prevention of endocranial infection by 
rigid antiseptic precautions in compound fractures of the skull and endo- 
cranial operations is one of the best arguments in support of the value of 
the antiseptic treatment of wounds. Intentional opening of the skull 
under strict aseptic precautions is seldom followed by suppurative endo- 
cranial inflammation. Compound fractures of the skull without fatal in- 
jury to the brain, if treated by strict antiseptic measures soon after the 
receipt of the injury, generally result in recovery of the patient. The 
most important indication in the treatment of these cases is to prevent 
infection of the wound, and thus guard most effectively against the oc- 
currence of endocranial suppuration. 

In the treatment of compound fractures of the skull, correction of 
mechanical difficulties is nothing as compared with the importance of 
carrying out full antiseptic precautions to prevent the fatal complications. 
Suppurative pachymeningitis is prevented by the same treatment which 



318 PKINCIPLES OF SUKGERY. 

secures an ideal aseptic healing in wounds of other parts. The prophylactic 
treatment aims at obtaining for the external wound, the fractured bones, 
and the exposed spaces underneath them a perfectly aseptic condition. 
The entire head should be shaved and the scalp rendered aseptic by wash- 
ing it with warm water and potash-soap, to be followed with a solution of 
corrosive sublimate (1 to 1000), and, lastly, with sulphuric ether or alco- 
hol. The wound of the pericranial tissues is enlarged sufficiently to ad- 
mit of thorough disinfection of the crevices between the fragments. Blood- 
clots and other foreign substances are to be sought for and removed, as 
infection is often traceable to imperfect treatment in this regard. Loose 
fragments are removed and kept in a warm solution of corrosive sublimate 
until they are reimplanted. Depressed fragments are elevated, and the 
space between the bone and the dura disinfected. If the dura has been 
lacerated the disinfection is carried further. Detached and contused brain- 
tissue is removed. All haemorrhage is carefully arrested, and after the final 
irrigation the dura is sutured, and, if necessary, a capillary drain of aseptic 
catgut or horse-hair inserted. 

In the majority of cases it is advisable to drain the external wound 
by the insertion of a tubular drain at the most dependent point. Reten- 
tion of the antiseptic dressing is secured best by applying a few turns of 
a plaster-of-Paris bandage. If, in spite of thorough primary disinfection, 
asepsis is not secured, secondary disinfection is to be instituted at once. 
This requires that the superficial sutures be removed. Detached bone 
is not to be reimplanted a second time, for fear of renewed infection. The 
whole surface is now disinfected by filling every sinus and depression with 
peroxide of hydrogen. After effervescence has ceased the fluid is washed 
away by irrigation with the ordinary antiseptic solutions. The peroxide 
of hydrogen will reach parts of the infected surface inaccessible to other 
antiseptic solutions. If any evidences, local or general, point to the ex- 
istence of a beginning inflammation of the dura mater and the subjacent 
membranes, the deepest portions of the wound are subjected to thorough 
disinfection, and tubular subdural drainage is established. If secondary 
disinfection prove unsuccessful the antiseptic dressing is to be removed 
and the moist antiseptic compress substituted, which is removed from time 
to time, when the deeper portions of the wound are cleansed by irrigation 
with an antiseptic solution. 

An external suppurative pachymeningitis is treated in the same way as 
an infected compound fracture of the skull. If it follow a compound fract- 
ure, loose, detached bones are removed, and the whole suppurating surface 
is disinfected; after which, tubular drainage is established. If it follow a 
fissured fracture, a sufficiently large opening is made in the skull to permit 
of free disinfection, and the accumulation of pus is prevented by the inser- 



BNDOORANIAL STJPPUBATION. 319 

tion o( a tubular drain. Suppuration between the dura mater and the cranial 
vault in an intacl skull is treated by making one or more openings in the 
skull for disinfection and drainage. A subdural abscess without fracture of 
the skull is to be accurately located by a systematic and accurate study of the 
clinical history of the case, and by reference to the etiology of the suppura- 
fcive process, and the information thus obtained can usually be corroborated 
by local symptoms which point to the exact location of the disease. The 
skull is opened with the chisel over the point where the abscess is suspected. 
If the dura bulge into the opening, is tense, and the pulsations of the brain 
cannot be felt, the surgeon may be almost sure that a subdural abscess is 
present, and confirms his suspicion by an exploratory puncture. If pus is 
found, the dura mater is incised, the cavity washed out with an antiseptic 
solution, and a tubular drain is inserted. A daily change of the dressing and 
washing out of the cavity with an antiseptic solution are necessary until sup- 
puration has nearly ceased; then the dressing is removed less frequently, 
and the drain is shortened as the cavity diminishes in size. If at the point 
where the abscess was localized the dura present no indications of subdural, 
intracranial pressure, but the surgeon feels sure otherwise of his diagnosis, 
it is justifiable to make a number of small exploratory punctures until he 
succeeds in locating the suppurating focus. If the abscess-cavity is large, 
and the first opening has been made at a point unfavorable to efficient drain- 
age, it is advisable to imitate the example of Macewen, to make a counter- 
opening in the skull and dura at the most dependent point, and to maintain 
through drainage until suppuration ceases. A localized suppurative pachy- 
meningitis, recognized in time, and located with sufficient accuracy to admit 
of radical treatment by operative measures, is an affection which the modern 
surgeon treats with every assurance of success. 

(b) Suppurative Leptomeningitis. — Inflammation of the arachnoid, 
without implication of the pia mater and surface of the brain, never occurs, 
and on this account we no longer speak of inflammation of any of these 
structures as separate lesions, but substitute the term leptomeningitis, by 
which is meant inflammation of the two inner envelopes of the brain, com- 
bined with cortical encephalitis. The surface of the brain is supplied in part 
with blood-vessels from the pia mater, and this intimate vascular connection 
establishes an equally intimate pathological relationship between these two 
structures. A septic leptomeningitis is a diffuse inflammation of the arach- 
noid, pia mater, and cortex of the brain, caused by infection with pus- 
microbes, and which, in the absence of all tendencies to localization, proves 
fatal before well-marked suppuration has occurred. Although septic inflam- 
mation of the meninges of the brain is usually caused by the ordinary pus- 
microbes, cases have been reported in which the streptococcus of erysipelas 
or the pneumococcus was found as the sole microbic cause, and Scherer 



320 PRINCIPLES OF SURGERY. 

records three cases of acute suppurative leptomeningitis due to the colon 
bacillus. The patients were nurslings. Etiologically and pathologically 
leptomeningitis resembles diffuse septic peritonitis. Examination of the 
contents of the skull reveals great vascularity, more or less serous transuda- 
tion, and softening of the gray matter of the brain. Microscopical examina- 
tion shows only a moderate emigration of the colorless corpuscles and the 
minute changes in the capillary vessels, which are characteristic of acute sep- 
tic inflammation. Suppurative leptomeningitis is characterized by the pres- 
ence of pus between and upon the membranes and upon the surface of the 
brain. Septic leptomeningitis always terminates in suppuration, if the life 
of the patient is sufficiently prolonged for emigration of leucocytes and their 
transformation into pus-corpuscles to occur. Septic leptomeningitis some- 
times appears within a few hours after a perforating wound of the skull. 
Bergmann relates the case of a child where a convex meningitis could be 
diagnosticated four hours after an injury of the skull. Konig reports a case 
that came under his observation where well-marked symptoms of leptomen- 
ingitis followed ten hours after perforation of the skull with the point of a 
sword. The wound was examined outside of the hospital with instruments 
that had not been disinfected. Ten hours after the injury the patient com- 
menced vomiting, and had a temperature of 39° C. The following day, wild 
delirium, strabismus divergens, and a temperature of 40° C. The second 
day, coma, rapid pulse, and death. The necropsy revealed diffuse septic lep- 
tomeningitis. The inflammatory product is found most abundant in the sub- 
arachnoid space. The effusion in this space is sometimes clear, raising the 
arachnoid; it contains, also, fibrin in flakes and membranes, or it presents 
the consistence and color of pus. Pus first appears along the course of blood- 
vessels in the pia in the shape of yellow streaks, which, when they become 
confluent, tend to considerable inflammatory thickening of the membrane. 
Pus may also appear in the ventricles by way of communication with the 
subarachnoidal spaces. On account of the absence of connective-tissue 
spaces, the inflammation of the surface of the brain remains superficial. If 
pus form here, it appears as small abscesses, which later may become con- 
fluent, causing superficial destruction of the brain-substance. If the surface 
of the brain is the seat of a contusion, suppurative encephalitis is more dif- 
fuse, and may lead to a diffuse acute abscess underneath the infected envel- 
opes. 

Besides wounds communicating with the atmosphere through which 
infection takes place, suppurative leptomeningitis, like pachymeningitis, can 
be caused by peripheral suppurative lesions, as phlegmonous inflammation 
of the soft tissues covering the skull, suppurative osteomyelitis of the cranial 
bones, and suppurative inflammation of the middle ear. In fractures at the 
base of the skull, infection frequently occurs through a ruptured tympanum, 



BNDOCEANIAL &UPPUBATION. 323 

01 through a wound of the soft parts in the naso-pharynx communicating 
directly with the meninges, 

Symptoms and Diagnosis. — The surgeon should be versed in the symp- 
tomatology of suppurative leptomeningitis, rather for the purpose of know- 
ing when not to interfere, by operative procedure, in cases of endocranial 
suppurative lesions, than to risk his reputation in a fruitless attempt in 
opo rating for an incurable disease. Diffuse septic and suppurative leptomen- 
ingitis are fatal diseases, and the surgical treatment will, in all probability, 
always remain of a purely prophylactic character. The symptoms of lepto- 
meningitis are always those of cortical encephalitis, from which it cannot be 
distinguished during life. The disease is often initiated by a chill, like 
phlegmonous inflammation in other localities, followed by high fever and 
other symptoms of septic intoxication. In other cases the chill is absent and 
the fever develops more insidiously. The rise of temperature, which is usu- 
ally abrupt, — the thermometer after a few hours shows an increase to 39° or 
•±0° C.j and, as a rule, presents but slight variations, — is caused by the absorp- 
tion of septic material from the infected and inflamed tissues. The intra- 
cranial pressure and fever give rise at once to symptoms which indicate the 
presence of cerebral irritation. Headache, morbid sensitiveness to external 
impressions, sleeplessness, restlessness, and psychical perturbation are some 
of the most constant and conspicuous early symptoms. If the patient fall 
into a short nap he starts up suddenly and behaves like a maniac. The pupils 
are usually contracted at first, but dilate as other symptoms of compression 
appear. Often they are unequal in size and respond only sluggishly to light. 
Localized and general convulsions frequently attend the stage of irritation. 
Vomiting and constipation are among the early symptoms. Paralysis of 
definite muscular groups, according to Bergmann, indicates extension of the 
disease to the region of motor centres. The face is suffused, the conjunctivae 
injected, and the pulsations of the carotid arteries increased. The pulse, at 
first increased in frequency, bounding and firm, becomes slower as cerebral 
compression advances. If, after its frequency has been reduced to 40 or 
50 beats per minute, it again becomes rapid, it is a sure indication of ap- 
proaching death. 

If the disease develop in the course of a perforating wound of the skull, 
the increased intracranial pressure is manifested by bulging of the dura mater 
into the wound, or, if the envelopes of the brain have been lacerated, by 
hernia of the brain. The prolapsed portion of the brain often sloughs, when 
putrefaction of the dead tissue occurs as an unavoidable result, and death 
from sepsis is hastened by such an occurrence. Bergmann has called the 
attention of the profession to the fact that leptomeningitis, affecting the 
convex surface of the brain, leads at once to paralysis of one extremity, or 
hemiplegia, by the extension of the disease to motor centres. Indications 



322 PRINCIPLES OF SURGERY. 

pointing to localized symptoms of central irritation can be explained by the 
same theory. Leptomeningitis at the base of the brain is not attended by any 
definite localized focal symptoms, and the retraction of the head takes place 
in consequence of the extension of the inflammation to the meninges of the 
spinal cord. Basilar meningitis in its advanced stage gives rise to a peculiar 
disturbance of respiration: the Cheyne-Stokes phenomenon. With the ap- 
pearance of compression of the brain the symptoms of central irritation sub- 
side and give place to the paralytic stage. The patient passes from a con- 
dition of listlessness gradually into a stupor, and finally into complete coma. 
With the appearance of monoplegia and hemiplegia some centres may be still 
in a condition of irritation, so that symptoms of irritation and paralysis may 
be manifested at the same time. During the paralytic stage the suffusion of 
the face disappears, the face is pallid, and the whole surface of the body cov- 
ered with a clammy, cold perspiration; the pupils dilate and no longer re- 
spond to light; the pulse becomes small and rapid, and death is preceded by 
relaxation of all sphincter-muscles. 

Treatment. — The prophylactic treatment has for its object the pre- 
vention of infection through wounds communicating with the contents of 
the skull. Eigid antiseptic treatment of all compound fractures of the skull 
must be carried out in the most pedantic manner. Fractures of the base of 
the skull, communicating with the atmospheric air through a ruptured tym- 
panum or through a lacerated wound in the naso-pharyngeal region, should 
be treated upon the same principles as a compound fracture of the vault of 
the cranium. If the t}-mpanum has been ruptured the external meatus is 
thoroughly disinfected and packed loosely with iodoform gauze, over which 
a filter of salicylated cotton is applied. If the fracture communicate with a 
wound of the naso-pharyngeal region, disinfection is aimed at by using an 
antiseptic nasal douche and plugging the posterior nares with tampons of 
iodoform gauze, which are to be removed daily, and, after using the nasal 
douche, are to be replaced by new ones. The prophylactic treatment of lepto- 
meningitis — caused by suppurating foci in the coverings of the skull, the 
middle ear, or in the cranial bones — can be carried out most successfully by 
early and rational treatment of the primary diseases. With the first appear- 
ance of the symptoms of leptomeningitis, the surgeon should lose no time in 
rendering the wound or primary suppurating depot aseptic by operative 
measures, combined with most rigid antiseptic precautions, with a faint hope 
that such measures may, in exceptional cases at least, lead to a successful 
issue by limiting the extension of the infection. As soon as the disease has 
become diffuse the prospects of a favorable termination are almost nil. It 
may be possible that multiple openings in the skull, with subarachnoid drain- 
age and frequent antiseptic irrigations or permanent irrigation, will, in the 
future, become an established and feasible method of treatment in such 



BRAIN-ABSI I 323 

cases. From a surgical stand-point such heroic treatment appears the only 
rational course to pursue in a (lass of patients otherwise doomed to certain 
death. The multiple port oral ions would have a potent influence in dimin- 
ishing the intracranial pressure: and drainage, combined with frequent or 
permanent irrigation, might — at least in a small percentage of cases — suc- 
ceed in sterilizing the extensive area of infection. 

BRAIX-ABSCESS. 

The term abscess of the brain should be limited to circumscribed col- 
lections of pus surrounded on all sides by brain-tissue. Suppuration occur- 
ring between the brain and its envelopes, from a circumscribed suppurative 
leptomeningitis, is not a brain-abscess. A brain-abscess is the result of a cir- 
cumscribed suppurative encephalitis. The acute form occurs when a con- 
tused portion of the brain becomes infected through a wound communicating 
with the atmospheric air, but, as this form will seldom, if ever, become the 
subject of successful operative treatment, our remarks will apply to abscess 
of the brain proper, or chronic abscess. A chronic circumscribed encephalitis 
may originate in a contused area of the brain, without any external wound or 
direct route of infection, from localization of pus-microbes in the locus 
minoris resistentia 1 . Such cases have been frequently observed where, weeks 
and months after the subsidence of the symptoms resulting from the imme- 
diate effects of a head injury, remote symptoms pointed to a central sup- 
purating focus in the brain. The occurrence of such grave remote conse- 
quences renders the prognosis, even after slight injuries to the skull, always 
more or less doubtful. In other instances an abscess forms around a foreign 
body that has lodged in the brain, and has remained for a long time without 
having given rise to any local or general disturbance. Infected penetrating 
wounds of the skull may heal, and the patient apparently recover perfect 
health, when at some remote time, and in direct causal connection with the 
previous infection, a chronic abscess develops, perhaps, some distance from 
the primary seat of infection. Most frequently such abscesses are caused by 
suppurative inflammation of the middle ear and suppurative osteomyelitis 
of the cranial bones. In size they vary from that of a pea to that of an entire 
hemisphere. They may remain stationary for twenty years, but the period 
of latency may pass into activity at any time. A large abscess in the white 
substance of a hemisphere may give rise to no functional disturbances what- 
ever, and can only be recognized by the terminal symptoms. In other cases 
the abscess cannot only be diagnosticated during life, but its location ac- 
curately determined by symptoms which point to destruction of a particular 
part of the brain. 

Symptoms and Diagnosis. — The first symptoms are insidious in their 
onset, and often of a very indefinite nature. The first thing noticed is, fre- 



32i PRINCIPLES OF SUKGEEY. 

quently, a hypersensitiveness and irritable temper of the patient, with more 
or less severe headache. Early loss of memory is often noticed, and the pa- 
tient becomes dull, sullen, unconcerned, and reckless in his business trans- 
actions. If the abscess involve any of the motor centres, or a considerable 
portion of fibres originating from them, monospasm or hemispasm, or mono- 
plegia or hemiplegia, follows as peripheral evidence of the central lesion. 
General convulsions, which sometimes occur at this stage, have less diag- 
nostic value than localized focal symptoms. Abscess of the brain seldom 
causes fever; on the other hand, the temperature is often subnormal. A 
sudden rise in temperature indicates that the abscess has reached the surface 
of the brain, and that a terminal leptomeningitis has developed. Eupture 
of an abscess into one of the ventricles is followed by general convulsions, 
paralysis, and death. Prominence of the dura over the abscess and absence 
or diminution of cerebral pulsation are important diagnostic signs, especially 
in cases where the abscess is located near the surface of the brain. Examina- 
tion of the exposed brain by palpation may elicit evidences of deep-seated 
fluctuation. In exceptional cases the portion of brain covering the abscess 
is firmer than normal from inflammatory infiltration (Eose). 

Gussenbauer states that in some cases the presence of the abscess can 
be ascertained by the existence of fluctuation. 

Prognosis. — An abscess in the brain is always an imminent source of 
danger to life. A considerable accumulation of pus in the brain, like in any 
other organ, is never removed by absorption. If the abscess remain in the 
active stage it gradually increases in size until it ruptures into one of the 
ventricles or reaches the surface of the brain, in either event resulting in 
complications which lead to a rapidly-fatal termination. It may remain in 
a latent condition for an indefinite period of time, but the life of the patient 
is always in jeopardy, as acute exacerbations may come on at any time. If 
an abscess form after a perforating injury of the skull, and the pus finds an 
exit through a permanent fistulous opening, the general health may remain 
sufficiently good to enable the patient to follow his occupation. A case came 
recently under my observation where I could introduce the probe to a dis- 
tance of four inches into the brain, and yet the general health remained un- 
impaired, although this condition had existed for years. The brain-abscess 
in this case developed in connection with purulent inflammation of the mid- 
dle ear. I have knowledge of another case, where a young man received a 
perforating wound of the skull, which was followed by the formation of an 
abscess of the brain that discharged externally. The patient filled, in a cred- 
itable manner, a responsible and important government position for thirty 
years, and died from another cause. The necropsy showed an abscess-cavity 
the size of an orange located in the anterior right lobe of the brain, which 
communicated with the external surface through a fistulous opening in the 



BRAIN-ABSCESS. 3*25 

skull. A few eases are reported where recovery followed the spontaneous 
discharge of the contents of the abscess through the ear or nose, but ordi- 
narily such an occurrence is followed by putrefaction of the remaining con- 
tents of the abscess-cavity and death from sepsis. 

Treatment. — All efforts to cure an abscess of the brain by external ap- 
plications or internal medication will be worse than useless in effecting re- 
moval of the pus by absorption. All exjjectant treatment is unavailing. 
Brain-abscess must be treated on the same principles as abscess in any other 
organ: by incision and drainage. The great difficulty in these cases is to 
make a sufficiently accurate diagnosis in regard to the exact location of the 
abscess. Before anything was known in reference to the subject of cerebral 
localization, Divpiyvtren- plunged a bistoury deeply into the brain, and was 
fortunate enough to hit an abscess which he suspected, and his patient re- 
covered. The same bold treatment has been frequently followed since, but 
not with the same brilliant result, as, in the majority of cases, either no ab- 
scess existed or the incision was made not into, but aside of, the abscess. 
Localized tubercular lesions of the brain giving rise to focal symptoms, re- 
sembling, in this respect, tumors or abscesses, are of frequent occurrence, 
and, if they can be recognized, furnish a contraindication to surgical inter- 
ference. Of 300 cases of brain-tumor, reported by Starr as occurring in per- 
sons under 19 years of age, 152 were tubercular. Eight of the 20 cases of 
tumor of the brain reported by Osier were tubercular. Of 28 cases that came 
under the observation of Mills, 7 were known to be of the same nature. Eenz 
cured an abscess of the brain by repeated aspirations through a fissure in the 
skull. The average surgeon, at the present time, would not undertake to 
incise a brain for abscess unless he had previously located the abscess by a 
careful study of focal symptoms and by a resort to exploratory punctures 
(Fenger). Bergmann condemns the use of the exploring-syringe for this 
purpose, but in the hands of those less skilled in cerebral localization than 
this eminent surgeon the exploring-needle will be regarded as a welcome 
and useful instrument of exact diagnosis. 

Cerebral Localization. — As the peripheral symptoms upon which the 
surgeon relies in locating an abscess in the brain are caused by irritation or 
destruction of the motor tracts or centres, it is absolutely necessary for him 
to become familiar with the topography of the motor centres. A. W. Hare 
gives a very practical instruction on cerebral localization in a paper published 
in the London Lancet, from which I quote: "In the parietal region, grouped 
around the fissure of Eolando, are the areas associated with movements of 
the extremities of the opposite side of the body, and, at the lower end of 
the fissure, those related to movements of the mouth and tongue. In the 
accompanying diagram the motor areas have been marked in their anatomical 
relations to the other structures of a normal head, dissected for the purpose, 



326 



PRINCIPLES OF SURGERY. 



showing the brain in its natural position. The areas associated with move- 
ments in neighboring regions of the body have been shaded alike in the 
figure. Thus, the areas A ; B, C, and D, bounding the fissure of Eolando 
posteriori}*, and 5 and 6, in front of the fissure, together with 2, 3, and I, at 
its upper end, are those in functional connection with the upper extremity; 
A, B, C, and D being concerned in the movements of the fingers, head, and 
wrist, 5 in a forward movement of the arm, 6 in pronation and supination 
of the forearm, and 2, 3, and -± in coordinated movements of the whole upper 
extremity. The areas 7, 8, 9, 10, and 11, indicated as having a common re- 
gion of motor representation, are related to movements of the tongue and of 
the muscles around the mouth. Area 1 represents, in part, movements of 
the lower extremity. In the same way areas of representation of general and 
of special sensation are located by Ferrier around the horizontal limb of the 




Fig. 126.— Motor Areas. 



fissure of Sylvius. It must not be overlooked that this mapping out of areas 
has an absolute exactitude only in the case of the species of ape upon which 
the experiments were performed. Its bearing in the human subject is one of 
great relative importance, but it must not be looked upon as a final statement 
of fact, in the case of man, until each area can be shown to be correctly 
placed, as it is by the accumulation of a sufficient number of clinical and 
of post-mortem observations directly confirming the method employed. 

"In the study of cranio-cerebral topography the surgeon has to rely on 
four primary landmarks in establishing a system of measurements. These 
are the glabella, or root of the nose, which bears a definite relation to the 
anterior limit of the cranial cavity, and the occipital protuberance, or inion, 
which bears a similar relation to its posterior end, corresponding to the junc- 
tion of the falx with the tentorium. The whole mass of the cerebrum is dis- 
posed between these two points, and they bear definite relations to its cor- 



BRAIN-ABSCESS. 32*2 

fcical matter, uninfluenced by the structure and contour of the bones forming 
the vault. The third constant landmark is the external angular process of 
rontal bone, which bears a relation to the lateral expansion of the frontal 
lobes, similar to that borne by the two prominences already mentioned, to 
the anterior and posterior extremities of the cerebrum. It has also a uniform 
relation to the fissure of Sylvius. Lastly, the parietal eminence is of value, 
since it marks the greatest lateral expansion of the substance of the hemi- 
sphere, and, as Turner has shown, bears a special relation to the submarginal 
convolution. To find the upper end of the fissure of Eolando by the use of 
these data, the surface measurement in the middle line of the head should 
be taken over the scalp from the glabella to the occipital protuberance. In 
ordinary adult heads this will vary from 11 to 13 inches; measured along 
this line from before backward, the distance from the glabella to the top of 
the fissure will be 55.7 per cent, of the total distance from the glabella to the 
occipital protuberance. The following scale shows the distance from the 
glabella to the top of the fissure in all ordinary heads: — 

When the distance from the glabella to the The distance from the glabella to the upper 

occipital protuberance is end of the fissure of Rolando is 

11 inches. 6 Vio inches. 

11 Va " 6 2 /s 

12 " 6»/s 

12 72 " 1 

13 " 7 7s 

"To find the top of the Eolandic fissure, Thane halves the distance from 
the glabella to the occipital protuberance, and, having thus defined the mid- 
dle point of the vertex, takes a point half an inch behind it as the location 
of the upper end of the fissure. Having thus ascertained the upper end of 
the fissure, it is desirable to determine its length and direction. The scalp 
measurement corresponding to its length is 3 3 / 4 inches. It runs from above 
downward and forward, its axis making an angle of 67 degrees with the 
middle line. 

••Wilson's c}'rtometer is an exceedingly useful aid in locating the fissure 
of Eolando. It consists of three strips of flexible metal and a tape for secur- 
ing it in situ. The method of its application is illustrated by Fig. 128. 

"The broadest, transverse strip passes coronally around the forehead, 
corresponding with the glabella and external angular process; the narrower, 
longitudinal strip passes backward from the glabella in the middle line to 
the occiput. This strip is marked with two scales of letters: capitals in its 
posterior fourth, and small letters about the middle of the strip. These two 
scales bear a relation to one another calculated to aid in the application 
of the instrument to an ordinary head. Measured from the glabella back- 
ward, the distance to any given small letter is 55.7 per cent, of the distance 
from the glabella to the corresponding capital letter; thus, when any capital 
letter will coincide with the top of the fissure, a third narrow, reversible strip 



328 



PRINCIPLES OE SURGERY. 



strikes on the longitudinal strip of metal, marking an angle of 67 degrees, 
opening forward and marked at 3 3 / 4 inches from its attached end. thus giv- 
ing the length and direction of the fissure on the surface of the head. To 
determine the exact location and direction of the fissure, a line is drawn from 
the external angular process of the frontal hone backward to the occipital 
protuberance, taking the shortest route between these points. Such a line 
drops a little toward the external auditory meatus, avoiding the greater con- 
vexity of the skull, which lies in the course of a horizontal line between the 
bony prominences. It usually passes about 1 / 2 inch above the meatus, and 




Fig. 12S. 



Fig. 127.— Wilson's Cyrtometer. 

Fig. 12S. — Wilson's Cyrtometer Applied. O, glabella: E A P, external angular procr-- fi 

fissure of Rolando, its position and direction marked by the lateral strip of metal. 



thus closely corresponds to the floor of the middle fossa, and behind runs 
parallel to and nearly in the same course with the attachment of the ten- 
torium and the posterior half of the lateral sinus. A measurement of 1 1 / s 
inches along this line, backward from the external angular process, marks 
the lower end of the fissure of Sylvius. From this point a straight line drawn 
to the centre of the parietal eminence accurately marks the course of the 
post ::ior limb of the fissure. The main line of the fissure follows the line 
of the squamo-parietal suture to its highest point, whence it continues its 
course to the parietal eminence. The middle meningeal artery, after groov- 
ing the inner surface of the great wing of the sphenoid, passes on to the ante- 



Ui; Al\- AIN'Kss. 



329 



rior angle of the parieta] bone, and is distributed to the dura mater lining 
the anterior and superior half of the hone. If the surgeon desire to expose 
the tip of the temporo-sphenoidal lobe, lie should open the skull behind the 
upper extremity of the greal wing of the sphenoid; if to expose Broca's con- 
volution, immediately in front o\' the same bony peninsula. The sites of the 
two operations are shown in Fig. 129." 

Opening of the Skull. — The first attempt to treat a brain-abscess by 
direct surgical intervention was made by Morand in 1751. The case was one 
in which the abscess communicated with the surface of the skin by a fistulous 




Fig. 129. — Head, Skull, and Cerebral Fissures. O. P., occipital protuberance; 
E A P, external angular process; S F, Sylvian fissure; A. its ascending limb; E. R., 
fissure of Rolando; P E, parietal eminence; M M A, middle meningeal artery; T S, 
tip of temporo-sphenoidal lobe; B, Broca's convolution. (Adapted from Marshall.) 



opening, which served as a guide in applying the trephine, and the fistulous 
tract was followed in approaching the abscess. Le Bond reported a similar 
case in 1844. Schede, however, was the first to propose and practice trephin- 
ing of the intact skull in the treatment of brain-abscess (1886). The opera- 
tive treatment of abscess of the brain presupposes an accurate diagnosis by 
means of cerebral localization and a careful study of the clinical and etio- 
logical aspects of the case. If symptoms of abscess of the brain arise, after 
a compound fracture of the skull, before the continuity of the skull has been 
restored, exploration can be done with a fine needle through a fissure, or at 
some point where fragments have been removed; and, if pus is found, a 



330 PRINCIPLES OF SURGERY. 

closed haemostatic forceps can be pushed along the side of the needle into 
the abscess, and the track enlarged by separating the blades before withdraw- 
ing the instruments. Into this track a drainage-tube is introduced, the 
abscess-cavity gently irrigated, and the wound disinfected and dressed anti- 
septically; or, a small quantity of peroxide of hydrogen can be injected into 
the abscess-cavity through the drainage-tube, which will not only force out 
the contents, but will also sterilize the walls of the abscess more thoroughly 
than any other antiseptic. If an abscess develop in the brain in an intact 
skull, or after the fracture has healed, the skull must be opened at a point 
immediately over the abscess. By means of the measurements given, or by 
the use of Wilson's cyrtometer, the motor centre or centres affected by the 
abscess are marked upon the shaved and disinfected scalp before the skull is 
exposed; and the exact location of the abscess is also marked on the skull 
by making a puncture through the scalp with a small perforator, so that the 
location can be recognized after the soft parts have been reflected. The bone 
is laid bare at this point by Horsley's flap, which is made by a horseshoe- 
shaped incision, the convexity of which is directed upward. The flap, with 
the periosteum attached, is turned downward. After all haemorrhage has 
been arrested the skull is opened, either by using a large trephine or, what 
is better, with a chisel; the button of bone or bone-chips are transferred into 
a warm, antiseptic solution, where they are kept until needed for reimplanta- 
tion, should this be deemed necessary or advisable. If the dura mater is 
tense and bulge into the opening, and cerebral pulsations are feeble or en- 
tirely wanting, the indications are that the skull has been opened near or 
directly over the abscess. The opening need not be larger than an inch in 
diameter. 

Methodical Exploration of the Brain. — Experiments and clinical ex- 
perience have shown that the brain can be explored in different directions 
with a fine, hollow, aseptic needle without any immediate or remote bad 
effects (Spitzka). The brain should never be incised for abscess until the 
abscess has been located by methodical exploration. An ordinary exploring- 
syringe with a delicate needle about 4 inches in length should be used for 
this purpose. The needle is pushed into the brain in the direction in which 
the abscess is suspected, and to the necessary depth, when aspiration is made 
and the result carefully noted. If no pus is found the needle is withdrawn or 
pushed forward in the same direction, and aspiration made at different 
points in its track; and, if no pus is found in that direction, it is withdrawn 
and pushed in another direction, and the same manoeuvres repeated. In 
this manner a large territory can be explored and even very small abscesses 
located. When the abscess has been located by this method of exploration, 
the needle is used as a guide for a small pair of haemostatic forceps, which is 
pushed forward along its side until the abscess has been reached, when it is 



BRAIN-ABSCESS. 

unlocked, the blades slightly separated, and as the instrument is withdrawn 
the track is sufficiently enlarged to permit the insertion of a rubber drain 
the size of an ordinary lead-pencil. The needle is only removed after the 
drain is in situ. Fenger, of Chicago, has written an exceedingly valuable 
paper on exploration of the brain, in the diagnosis and treatment of abscess 
oi' the brain, in which he has furnished abundant proof both of the harmless- 
ness and utility of this procedure. 

Alter the abscess has been opened and drained, it is advisable to wash 
it out gently with some non-irritating and yet effective antiseptic solution, 
either with half of a 1-per-cent. solution of acetate of aluminum or a 2-per- 
cent, solution of boric acid. 

As the abscess-walls are never firm, every precaution must be taken to 
prevent overdistension, but gentle irrigation is continued until the fluid re- 
turns clear. If the skull has been opened by removing a disk of bone by 
trephining, an opening in this must be made at its lower margin, which will 
permit bringing the drainage-tube out to the external surface after implanta- 
tion. If bone-chips are reimplanted, a space for the drain must be left in the 
most dependent portion of the opening. The drainage-tube is brought out 
at one of the lower angles of the wound or through a button-hole in the flap. 
The flap is secured in its position by a requisite number of sutures. Daily 
changes of dressing is required until suppuration diminishes, when the drain 
is shortened from time to time and the dressing changed less frequently. 
The drainage-tube is not to be removed until the abscess-cavity is closed, as 
otherwise a relapse would be liable to occur which would require a repetition 
of the first operation. The most unsatisfactory aspect of the surgical treat- 
ment of abscess of the brain is the fact that in some instances multiple ab- 
scesses are present: an occurrence which is beyond the limits of the present 
means of diagnosis. In such cases the surgeon may cure one abscess, but the 
patient succumbs from the effect of those that have not been discovered. 
The appearance of a hernia cerebri, after the evacuation and drainage of an 
abscess of the brain, is a condition which points to the existence of an addi- 
tional abscess or abscesses. Should such a condition appear during the after- 
treatment of an abscess of the brain, treated by evacuation and drainage, it 
would furnish a strong temptation to resort to another methodical explora- 
tion with a view of subjecting additional abscesses to the same radical treat- 
ment. Should the first opening into an abscess of the brain not be suitable 
for effective drainage, it would be well to follow the example of Macewen and 
open the skull at a lower point, tunnel the intervening portion of the brain, 
between this opening and the abscess-cavity, with haemostatic forceps, and 
thus establish an additional and more efficient route for drainage. In the 
surgical treatment of abscess following suppurative inflammation of the mid- 
dle ear, it is well to remember that in these cases the abscess is usually located 



332 PRINCIPLES OF SURGERY. 

in the vicinity of the petrous portion of the temporal bone, and that in 
exploring the brain the needle should be inserted in this direction. 

EMPYEMA. 

Empyema is a collection of pus in the pleural cavity. It is always the 
result of a suppurative pleuritis. 

Bacteriological Studies. — A penetrating wound of the pleural cavity is 
more frequently followed by infection with pus-microbes and suppurative 
pleuritis than perforation of one of the bronchial tubes, as in the latter acci- 
dent the atmospheric air entering the pleural cavity has undergone a process 
of filtration during its passage through the respiratory tract. Suppurative 
pleuritis, occurring without direct infection through a perforation in the 
thoracic wall or one of the bronchial tubes, is alwa}^s caused by localization 
of pus-microbes within or upon the serous membrane lining the pleural cav- 
ity. Localization of pus-microbes occurs in the pleura or pleural cavity 
either as a primary or secondary infection. Frankel made a bacteriological 
study of 12 cases of empyema. In 3 cases, in which no special cause could 
be traced, the pus contained exclusively the streptococcus pyogenes. In 3 
cases the pus contained only pneumococci. Other authors have found in 
such cases also other pus-microbes. Frankel believes that when this is the 
case they have localized in consequence of a secondary invasion. Charrin 
found, in the pus of an empyema occurring in a puerperal woman, pure cult- 
ures of the proteus vulgaris. The presence of streptococci in the pus from 
a suppurating pleural cavity presents nothing characteristic, as the microbe 
is also found in cases in which the empyema is secondary to pneumonia and 
tuberculosis. On the other hand, he assigns to the pneumococcus, in pus 
taken from a pleural cavity, a diagnostic significance, as it proves, beyond all 
doubt, that the suppurative pleuritis occurred in the course of a pneumonia 
as a secondary affection; consequently, its presence in the pus is positive 
proof that a pneumonia exists or has existed, even if the clinical and physical 
symptoms were not sufficiently clear to indicate its existence. In 4 cases the 
empyema had a tubercular origin, in 2 of which pneumothorax was present 
at the same time. The presence of the bacillus of tuberculosis in the pus is 
not easily demonstrated, but the absence of this microbe is no sign that the 
disease is not tubercular, as inoculations with pus in animals almost con- 
stantly produce typical tuberculosis. In the pus of tubercular pyopneumo- 
thorax, if microorganisms are present, the bacillus of tuberculosis can be 
found, and the pus shows no tendency to undergo putrefactive changes, in 
contradistinction to empyema occurring in non-tubercular subjects, in whom 
spontaneous discharge through the bronchial tubes takes place. Senator 
maintains that putrefaction is prevented by the parenchyma of the lungs 
acting as a filter, preventing ingress of bacteria with the inspired air, and 



EMPYEMA. 333 

by the presence of a Large amount of carbonic-acid gas in the air of the 
cavity, as it is well known thai microbes do not thrive so well in such an 
atmosphere as in ordinary air. Ehrlich has made an interesting bacterio- 
logical examination of the pus in L9 cases of empyema; in only 7 of these 
could the bacillus of tuberculosis be found; in the remaining 12 this microbe 
could not be detected, and upon this negative ground the existence of tuber- 
culosis was excluded. Further observation in these cases after operation cor- 
roborated the diagnosis. He asserts, therefore, that, in the purulent pleu- 
ritic exudation in tubercular patients in empyema and pyopneumothorax, 
the presence of the specific microbic cause can always be demonstrated. This 
author places the greatest importance on a bacteriological examination of 
the pus as a means of differential diagnosis between suppurative and tuber- 
cular empyema. A serous effusion is not infrequently transformed into an 
empyema by a change of the predominant bacteriological cause. In a num- 
ber of cases I found it necessary to aspirate the chest for the removal of a 
copious effusion. The fluid removed at the first aspiration was clear serum; 
the second aspiration removed a slightly turbid fluid, and the third aspira- 
tion yielded a distinctly sero-purulent fluid; while the fourth aspiration re- 
vealed a well-marked empyema. In all of these cases the subsequent history 
and termination showed that tuberculosis was the primary cause of the ef- 
fusion. Infection of the tubercular foci with pus-microbes, and the entrance 
of these into a cavity already changed by disease, altered the type of the in- 
flammation and the character of the effusion. Putrefaction of the products 
of suppurative pleuritis occurs occasionally without the presence of a direct 
communication of the pleural cavity with the atmospheric air. I have seen 
2 cases of this kind, and both recovered after radical operation. In such 
instances w^e must take it for granted that saprophytic bacilli find their way 
into the pleural cavity through the respiratory passages and the parenchyma 
of the lungs, and select the products of coagulation-necrosis for their nu- 
trient medium. The pus in such cases is exceedingly fetid, thin, and usually 
contains large shreds of fibrin. The ptomaines of the putrefactive bacteria 
increase the fever and other symptoms of septic intoxication. 

Diagnosis. — The presence of a considerable quantity of fluid gives rise 
to well-marked clinical and physical symptoms. Aside from the ordinary 
symptoms which point to a suppurative inflammation in other localities, such 
as chill, fever, pain, loss of appetite, the patient complains of difficulty of 
breathing, especially on lying down, and sometimes, but not always, of a 
short, hacking cough. On physical examination it becomes apparent that a 
part or nearly the entire pleural cavity is occupied by a fluid. Dullness on 
percussion and absence of respiratory and voice sounds over the area occu- 
pied by the fluid, and displacement of adjacent organs by the intrathoracic 
pressure are signs which cannot be well simulated by anything else than 



334 PRINCIPLES OF SURGERY. 

accumulation of fluid in the pleural cavity. Bulging of intercostal spaces, as 
a rule, is more marked in empyema than hydrothorax. In empyema the sub- 
cutaneous tissues on the affected side are often slightly (Edematous and the 
superficial veins are usually enlarged. In empyema of the right pleural cav- 
ity the liver is pushed in a downward direction, while the heart is displaced 
toward the left side. In empyema of the left side the apex-beat of the heart 
can quite frequently be felt on the right side of the sternum. A temperature 
of 100° to 101° F. in the morning and 101° to 103° F. in the evening, con- 
tinued for several weeks, speaks strongly in favor of empyema. A positive 
diagnosis always rests on demonstrating the presence of pus in the pleural 
cavity, which can be done, without danger and without pain worth mention- 
ing, by an exploratory puncture with an ordinary hypodermic needle. In 
puncturing the chest for exploratory or therapeutic purposes, it should be 
borne in mind that the needle should be inserted in a direction which corre- 
sponds to the centre of the intercostal space; consequently in an oblique 
direction from below upward. If no contraindications present themselves, 
the exploratory puncture should be made at the place where, later, the radical 
operation will be performed; that is, in the axillary line, between the sixth 
and seventh or seventh and eighth ribs. If the needle is perfectly aseptic 
no harm will result, even should the lung or liver be punctured. 

Prognosis. — Simple, uncomplicated suppurative pleuritis offers a favor- 
able prognosis if subjected to early radical treatment. The prognosis is more 
favorable in children than in adults, and in recent than in old cases. In long- 
standing empyema the lung becomes atelectatic from compression, and its 
full expansion is also prohibited by numerous firm adhesions. In children 
partial expansion of the lung is compensated for by retraction of the yielding 
chest-wall, enabling the pleural cavity to close; while, in the adult, incom- 
plete expansion of the lung results in a physical condition which renders 
definitive healing a difficult, if not even an impossible, occurrence. Ad- 
vanced pulmonary tuberculosis complicated by empyema constitutes a con- 
traindication to radical operation, as the patient is already affected by a dis- 
ease which almost necessarily leads to a fatal issue, and a radical operation 
would only hasten this termination. 

A fistulous communication between a bronchial tube and the pleural 
cavity, resulting from a rupture of an empyema in this direction, in excep- 
tional cases, leads to a spontaneous cure, but more frequently becomes a cause 
of retardation of recovery after an operation. 

Treatment. — An empyema is nothing more nor less than an abscess in 
the pleural cavity, and should be treated as such. There can be no doubt that 
in exceptional instances a cure has been effected by aspiration. This method 
of treatment promises more in children than in adults, and it is also in the 
former that the radical operation has yielded the best results; hence it is not 



i:mi-\ i.m l 335 

advisable to have recourse to an uncertain procedure if a radical operation 
accomplish the same result with greater certainty, more speedily, and with 
do greater immediate and remote risks to life. It is a good plan in every 
o combine aspiration with exploration, for the purpose of improving the 
conditions for a radical operation. By aspiration we demonstrate the pres- 
ence of pus in the pleural cavity, and, by removing the fluid completely or 
in part, Ave aid the expansion of the lung, which, by the time the radical op- 
eration is performed, has become adherent lower down. Aspiration is to be 
followed, in the course of two or three days, by a radical operation. By a 
radical operation we understand incision of the pleural cavity and draining 
i he same. The operation for empyema by incision and drainage must always 
be done under the strictest aseptic precautions, as any mistake or negligence 
in this regard is exceedingly liable to be followed by infection with putre- 
factive bacteria: an occurrence which would greatly increase the danger from 
sepsis. Xothing but perfectly aseptic material must be used, and the whole 
chest of the patient and the hands of the operator must be thoroughly dis- 
infected by washing with hot water and potash-soap, and disinfecting with 
a l-to-1000 solution of sublimate, and finally with alcohol. The instruments 
must be boiled for at least ten minutes in a 1-per-cent. soda solution. 

(a) Incision. — If an empyema is perforating the chest-wall and appears 
as a subcutaneous abscess, the incision is made through the centre of the 
abscess and parallel to the ribs. If no such indication is present, the incision 
should be made over the centre of the sixth rib and parallel to it on the right 
side, and over the seventh on the left, at a point corresponding with the 
axillary line. It must be about 4 inches in length and extend down to the 
bone. 

(b) Resection of Rib. — The soft parts, with the periosteum, are re- 
flected with an elevator, which is then passed between the periosteum and 
rib, posteriorly, from below upward, and the periosteum separated to the ex- 
tent of 1 1 / 2 inches. If the elevator is kept in close contact with the bone, 
there is no danger of injuring the intercostal vessels or nerves, nor of open- 
ing the pleural cavity prematurely. With the elevator the rib is raised, and 
a section 1 1 / 2 inches in length is removed with a pair of heavy bone-forceps. 
After the removal. of the bone all haemorrhage is carefully checked. If the 
pleura feel tense and bulge into the wound, there is no necessity of making 
another exploratory puncture. If this is not the case, as a matter of precau- 
tion, another puncture can be made, at this stage of the operation, to satisfy 
the surgeon of the presence of pus underneath. The incision into the pleura 
is then made with a bistoury, in the centre of the periosteal gutter, through 
this membrane and the pleura, into the cavity of the chest. This incision 
must be large enough to allow the insertion of two drainage-tubes the size of 
the little finger. The deep incision in the soft parts can be readily dilated 



336 PRINCIPLES OF SUEGEEY. 

to the requisite extent by the insertion of the index finger, which may also 
be used in interrupting the flow. 

(c) Evacuation of Pus and Removal of Membranes. — A great deal of 
information is gained, as soon as the incision into the chest has been made, 
in reference to the expansibility of the lung. If this has not been much im- 
paired, the pus will continue to escape with much force, especially during 
inspiration. Eapid evacuation is attended by some danger, from overdis- 
tension of the heart and vessels in the lung, and must be guarded against by 
interrupting the flow, from time to time, by inserting the index finger into 
the opening. If the lung expand promptly, its lower margin can often be 
seen through the opening toward the end of evacuation. The more the lung 
expands, the less the amount of air rushing through the opening into the 
chest. In order to prevent syncope upon the sudden diminution of intra- 
thoracic pressure, during evacuation of the pus, I have been in the habit of 
administering, before the anaesthetic is given, 1 / 100 grain of atropia with 1 / 8 
grain of morphia, hypodermically, with an alcoholic stimulant, by the stom- 
ach or rectum. In cases of empyema with a bronchial fistula, and in cases 
where respiration was so much embarrassed that I deemed the administration 
of an anaesthetic hazardous, I have repeatedly made the radical operation 
without narcosis, and the remedies which have just been mentioned answered 
an excellent purpose in diminishing the pain. If, as is so often the case, the 
pleura is lined with thick, partially-detached membranes, these should be 
removed with a dull curette, as they are invariably infected with pus-mi- 
crobes, and their presence in the pleural cavity would prolong the infection 
and retard recovery. 

(d) Irrigation. — Irrigation of the pleural cavity immediately after the 
operation is positively contraindicated if a bronchial fistula is present, and it 
is superfluous if no putrefaction is present. In fetid empyema the cavity is 
washed out with warm, salicylated water until the fluid returns clear. None 
of this solution should be allowed to remain in the pleural cavity. 

(e) Drainage. — Eib resection should alwa}'S be done in operations for 
empyema, as the space thus created offers ample room for the insertion of a 
large drain. I have frequently seen, after incision and drainage through an 
intercostal space, circumscribed destructive processes of the margins of both 
ribs from pressure caused by the drainage-tube. Such pressure is not only 
a source of pain, but interferes also with free drainage. Eesection of such a 
small portion of a rib does not add to the gravity of the operation, and is of 
the greatest utility in the subsequent management of the case. The best 
drain is a fenestrated rubber tube the size of the little finger, or two rubber 
tubes, somewhat smaller, stitched together. The tube should be from 4 to 
6 inches in length, and always secured externally with a large safety-pin, to 
prevent its slipping into the pleural cavity. Xonobservance of this little 



EMPYEMA. 337 

precaution has resulted in a great deal of trouble from drains becoming lost 
in the pleural cavity. The necessity of making a counter-opening and of 
establishing through drainage does not arise often, but, when such a pro- 
cedure becom< - ssaiy, it can readily be done with a large Pean forceps, 
which can be introduced into the anterior opening, and, by pushing it 
through the intercostal space behind, which has been selected for the coun- 
ter-opening, an incision is made down upon its point, after which the 
opening is dilated and a long drain drawn through both openings. After 
completion of the operation a large antiseptic dressing is applied. 

After-treatment. — Daily change of the dressing and antiseptic irriga- 
tion will be necessary in fetid empyema, if the primary disinfection has not 
proved successful, in rendering the cavity free from putrefactive bacteria and 
necrosed material. In ordinary cases the dressing is not removed until it 
becomes saturated with the discharges, or if the temperature indicate the 
retention of septic material. Should, at any time, evidences of putrefaction 
or sepsis develop, antiseptic irrigations are positively indicated. A saturated 
solution of acetate of aluminum, an aqueous solution of tincture of iodine, 
a 2-per-cent. solution of boric acid, Thiersch's solution, or salicylated water 
can be used for this purpose, always using the solutions at blood-heat, as the 
irrigation of the pleural cavity with a cold or cool solution has, in a number 
of cases, resulted in death from shock. In one of my cases the wife of the 
patient irrigated the pleural cavity with what she afterward called a cool 
solution, and the patient died suddenly with symptoms of collapse. In an- 
other case, a patient 5 years of age, I made the irrigation myself, using only 
water, the temperature, as I afterward ascertained, being below blood-heat, 
when the patient suddenly became pulseless and the respiration ceased. 
Artificial respiration had to be continued for a considerable length of time, 
when, to my great relief, the child commenced to breath spontaneously and 
the pulse and color of the face returned. This experience warned me to ex- 
ercise care in using solutions of a proper temperature in irrigations of the 
pleural cavity. The final expansion of the lung and obliteration of the pleu- 
ral cavity are accomplished by the granulating process. The drain should be 
disinfected every time, and before it is reinserted it should be dusted with 
iodoform. 

(a) Multiple Resection of Ribs. — In cases of empyema where, after a 
radical operation, only partial expansion of the lung takes place, and the 
pleural cavity cannot close on account of the unyielding nature of the chest- 
wall, Estlanders operation of multiple resection of ribs is indicated. The 
operation consists in removing sections of 3 to 6 centimetres in length of all 
the ribs over the abscess-cavity, for the purpose of allowing the chest-wall to 
sink in, and thus remove the mechanical obstacle to closure of the pleural 
cavity. Through one incision over an intercostal space 2 adjacent ribs can 



338 PRINCIPLES OF SURGERY. 

be removed. If more than 2 ribs have to be resected, I prefer to make a 
single incision in the direction of the axillary line, through which, after dis- 
secting back the superficial soft parts for 1 or 2 inches on each side of the 
incision, 6 or 8 ribs can be readily resected. Estlander's operation is abso- 
lutely valueless in cases where the lung is almost completely collapsed, where 
the pleura has become much thickened and unyielding, as in such instances 
even the most extensive resection of ribs would fail in correcting the me- 
chanical difficulty in the way of a definite healing of the pleural abscess. 
The operation is also contraindicated where farther expansion of the lung 
depends on incurable lesions of that organ. 

(b) Thoracoplastic Operation. — In obstinate cases of empyema, where 
even Estlander's operation fails in effecting a cure, and where the difficulties 
in the way are of a purely mechanical nature, Schede has described a pro- 
cedure which, in reality, is a plastic operation. He not only makes resection 
of several ribs, but resects the entire thoracic wall over the cslyHj, with the ex- 
clusion of the skin. He makes a skin-flap with its base directed upward, cor- 
responding in size to the cavity underneath, and then removes all of the ribs 
in the region to the same extent, and finally resects the remaining portion of 
the chest-wall. This operation exposes one side of the cavity completely, 
and the opposite wall is then covered with the skin-flap. The flap is not 
sutured, but kept in place by a compress of loose gauze corresponding in size 
and shape to the abscess-cavity. This operation deals more effectually with 
the mechanical difficulties resulting from imperfect expansion of the lung 
than Estlander's multiple resection of ribs, and will always be resorted to in 
proper cases where less heroic measures have failed in accomplishing the de- 
sired result. 

LUNG- ABSCESS. 

The successful treatment of abscess of the lung by operative procedure 
is one of the many achievements of modern surgery. Bull, of Xorway, has 
collected 26 cases of abscess of the lung treated by incision and drainage, of 
which number 4 were cured, 6 improved, 9 relieved, and 7 were not benefited 
by the operation. Abscess of the lung is the result of a circumscribed sup- 
purative inflammation of lung-tissue, or it develops after an attack of pneu- 
monia or gangrene of the lung. If it follow pneumonia, a part of the solid- 
ified organ fails to undergo resolution and becomes the seat of secondary 
infection with pus-microbes. The abscess then forms by liquefaction of the 
inflammatory product, the same as in other tissues. Gangrene of the lung 
can only take place if the tissues are destroyed by the intensity of the pri- 
mary infection or if they become later the seat of secondary infection with 
putrefactive bacteria through the respiratory passages. If the gangrenous 
portion is limited in extent, and life is prolonged for a sufficient length of 



1. 1 NG-ABSCESS. 339 

time, the dead tissue becomes detached, and is frequently eliminated in frag- 
ments through a bronchial fistula by coughing. The cavity which is formed 
in this manner suppurates, and is etiologically and clinically an abscess. A 
circ u inscribed suppurative pneumonia, resulting in the formation of an ab- 
scess, may occur around a foreign body which has lodged in one of the bron- 
chial tubes. The clinical history of every abscess of the lung points to an 
antecedent suppurative pulmonary inflammation, with or without gangrene. 

Diagnosis. — The surgeon diagnosticates the existence and location of 
an abscess in the lung by the same methods and means as when it is located 
in another organ. If, from the clinical history and physical examination of 
the chest, he has reason to suspect that the cavity is of a non-tubercular 
nature, he locates it as accurately as he can by the physical signs which are 
presented, and then demonstrates, ad oculum, the existence of a pus-cavity 
by exploring the lung with the needle of an exploring-syringe. Fenger was 
the first one in this country to locate an abscess of the lung by this means 
of examination, and to adopt treatment upon strict aseptic surgical prin- 
ciples. Microscopical examination of the sputum is of great value in de- 
termining whether an abscess is tubercular or the result of a suppurative 
inflammation. 

Methodical Exploration of Lung for Abscess. — If the physical symptoms 
point to a non-tubercular abscess in the lung, with or without a bronchial 
fistula, the surgeon will be able to determine the portion of lung involved 
by ascertaining over the abscess a limited area of dullness caused by con- 
densation of lung-tissue around the abscess, and, if the abscess-cavity is filled 
by pus, by the presence of this fluid. If a bronchial fistula exist, ausculta- 
tion will reveal the usual symptoms, caused by a cavity in the lung partially 
filled with fluid. By means of percussion and auscultation it is ascertained 
where the abscess is nearest the surface, and at this point the lung is explored 
with a hollow needle, not exceeding in diameter an ordinary knitting-needle, 
and at least 4 inches in length, attached to a hypodermic or exploring- 
syringe. As a matter of course, the needle and surface must be ren- 
dered perfectly aseptic before the puncture is made. The needle is pushed 
through an intercostal space, corresponding to the location of the disease, 
in the direction of the centre of the inflammatory focus; its entrance into 
the abscess-cavity is attended by a sudden loss of resistance. Aspiration is 
now made, and if pus is found the diagnosis is made. If no pus is withdrawn 
the needle is pushed forward, and at different points aspiration is made. If 
pus is not found in one direction, the needle is partly withdrawn and pushed 
in another direction, and this and additional tracks are explored in the same 
manner until the cavity is located. An abscess-cavity only partially filled 
with pus may be entered at several points without finding pus. If the sur- 
geon feel sure that the needle is in a cavity, it might be well to make aspira- 



340 PRINCIPLES OF SURGERY. 

tion with the patient in different positions, so as to bring the pns in con- 
tact with the needle; or, if this fail, to inject a mild antiseptic solution 
through the needle, which will be conghed up if the injection reach the cav- 
ity. No operation on the lung must be undertaken for abscess until the exact 
location of the abscess has been demonstrated by exploratory puncture. 

Operation. — The first steps of an operation for abscess of the lung are 
the same as in radical operations for empyema. At least a section of one rib 
is removed. With few exceptions, the lung will have become adherent to the 
parietal pleura at the time the operation is undertaken, but if this is not the 
case it will become necessary to leave the operation unfinished rather than 
to risk an onset of suppurative pleuritis after the lung-abscess has been 
opened. In such a case, after the parietal pleura has been incised, the wound 
should be tamponed with iodoform gauze, and the opening of the abscess 
postponed until adhesions have formed. If adhesions make it safe to 
complete the operation, the abscess is again accurately located by exploring 
with a needle, and, while the needle is in the cavity, the lung is incised with 
the knife-point of Paquelin's cautery, using the needle for a guide. By mak- 
ing the incision with the actual cautery troublesome parenchymatous haemor- 
rhage is avoided, and at the same time the intervening lung-tissue is pro- 
tected against infection by a tubular eschar; and last, but not least, such an 
opening is better adapted for subsequent free and effective drainage. A rub- 
ber drain, as large as the track made by the cautery, is inserted into the cav- 
ity. If the abscess communicate with the bronchial tubes irrigation cannot 
be practiced; if this is not the case the abscess is disinfected by irrigation 
with an antiseptic solution. In either case iodoformization of the abscess- 
cavity by dusting the drain with iodoform should always be done. If the first 
opening fail to drain the abscess satisfactorily, it may become necessary to 
make a counter-opening at the most dependent part of the cavity and estab- 
lish another and more efficient point for drainage (Vogt-Mosler). 

The after-treatment in cases of lung-abscess treated by incision and 
drainage is the same as after radical operations for empyema. 

SUPPURATIVE PERICARDITIS. 

A suppurative inflammation of the internal surface of the pericardium 
results in an abscess of the pericardium, or empyema pericardii. The disease 
is characterized by clinical evidences which indicate the presence of a sup- 
purative inflammation and by physical signs which point to the presence of 
fluid in the pericardial sac. In some of the cases which have been reported 
it was attended by little general disturbance, no chill, and but little rise of 
temperature. If it occur as a complication of some other affections, the 
symptoms of the latter often obscure almost completely those of the former. 
In some of the cases the presence of pus was indicated by oedema in the prae- 



SI PP1 i; VTIVK PERICABDITIS. 341 

cordial region. If the quantity of pus is large, the pericardium is distended 
and the intercostal spaces in front of the effusion are more prominent than 
on t he opposite side. The area of dullness, which can be mapped out accu- 
rately by percussion, corresponds with the size of the expanded pericardium. 
The impulse of the heart is felt less distinctly and is more diffuse than in a 
normal condition. A copious pericardial effusion always gives rise to orthop- 
nea. Positive proof of the existence of a collection of pus in the peri- 
cardium can only he obtained by an exploratory puncture. 

Puncture and Aspiration of Pericardium. — Puncture and aspiration of 
fluid from the pericardium is a comparatively harmless procedure, if it is 
practiced with ordinary skill and care. 

West reports 79 cases of paracentesis pericardii. Of this number, the 
operation was the cause of death in 1 case only, and in this instance the trocar 
which was used perforated the right ventricle. Six of the cases died during 
the first twenty-four hours, while in the remaining cases the immediate effect 
of the operation was beneficial, and a number of cases recovered permanently. 
In puncture of the pericardium for diagnostic or therapeutic purposes, the 
trocar should always give way to a medium-sized needle of an exploring- 
syringe or aspirator. The puncture is made under strict aseptic precautions. 
The structures to be avoided are the internal mammary artery, the pleural 
cavity, and the heart. The safest place for puncture is, in ordinary cases, 
the fifth left intercostal space, about half an inch or an inch from the margin 
of the sternum, through which the needle should be pushed in a slightly 
upward and outward direction, so as to avoid wounding the heart. It has 
to travel 1 3 / 4 to 2 inches before it enters the pericardial cavity. If pus is 
found the case must be treated by 

Incision and Drainage of the Pericardium. — Instead of using a trocar, 
it is much better to make an incision in the fifth intercostal space, using 
the needle w r ith which the exploratory puncture was made as a guide. The 
same precautions to prevent syncope as were recommended in the radical 
operation for empyema should be resorted to in these cases, and chloroform 
is preferable to ether as an anaesthetic. The intercostal incision need not 
exceed an inch in length, and, as soon as the pericardium has been opened 
sufficiently to allow the escape of pus, a dressing-forceps may be inserted, and 
the opening enlarged sufficiently to enable the introduction of a drainage- 
tube the size of an ordinary lead-pencil. It has been recently recommended 
that pericardial incision should be preceded by rib resection, and some have 
gone so far as to propose a limited temporary resection of the chest-wall as 
a preliminary step to incision and drainage. 

Irrigation of the pericardial cavity is to be avoided unless suppuration 
is complicated by putrefaction. The drainage-tube should not project suf- 
ficiently into the pericardial sac to come in contact with the heart, and should 



342 PRINCIPLES OF SURGERY. 

always be of soft material, so as not to injure the heart should it be too long. 
The antiseptic dressing can be retained most effectually with several strips 
of rubber adhesive plaster, which should be long enough to encircle the whole 
chest. Stoll, of Warsaw, has reported a successful operation for suppurative 
pericarditis. The patient was an exhausted and emaciated soldier, 21 years 
of age. After the sternum was trephined the pericardium was freely opened 
at the level of the second intercostal space. Two months after the operation 
examination showed that the pericardial sac was completely obliterated. 
Gussenbauer, in a patient 15 years of age suffering from suppurative peri- 
carditis after osteomyelitis, resected part of the fifth rib near the sternum 
before incising the pericardium, and the patient recovered. This modifica- 
tion of the ordinary operation by incision through the fifth intercostal space 
will occasionally present decided advantages in the surgical treatment of 
pericardial empyema. 

SUPPURATIVE PERITONITIS. 

A great deal of confusion has recently arisen in the use of the terms 
septic and suppurative peritonitis. Etiologically, they are identical; clin- 
ically, they differ in so far that septic peritonitis is generally diffuse, and 
leads to a rapidly fatal termination; while what is known as suppurative 
peritonitis is more frequently circumscribed and more amenable to surgical 
treatment. Both forms are caused by infection with pus-microbes. In the 
septic variety death results from intoxication before the pus-microbes have 
had time to produce their specific pathogenic effect on the histological ele- 
ments which are destined to become converted into pus-corpuscles. In sup- 
purative peritonitis the pus-microbes are either less in number or they meet 
with conditions less favorable to the production of a fatal amount of toxins, 
or, finally, the peritoneum is in a condition which is unfavorable to the en- 
trance of pus-microbes or their toxins into the circulation. 

Bacteriological and Experimental Researches. — A number of original 
investigators have studied the etiology of peritonitis experimentally, and 
their work has been of great practical value in showing that suppurative 
peritonitis is not only caused by the action of pus-microbes, but that it is 
equally essential that certain conditions must be present in the peritoneal 
cavity which enable the pus-microbes to produce their specific pathogenic 
effects. Pawlowsky made ten series of experiments on 101 animals. The 
chemical irritants, or cultures, were introduced into the peritoneal cavity 
through the cannula of a small trocar under strict aseptic precautions, and 
the small wound was carefully sealed with iodoform collodion. The first 
series consisted of experiments with croton-oil on 3 dogs and 9 rabbits. The 
amount of croton-oil injected in each case varied from 6 drops to 1 / 10 drop. 
The smallest doses produced no effects. Large doses caused a severe, acute, 



SUIMMKATI vi; PERITONITIS. 343 

hemorrhagic peritonitis the intensity of which Mas proportionate to the 
quantity o( the irritant injected. The peritoneal exudation, under the micro- 
scope, was >ien to contain red and white blood-corpuscles. Inoculations of 
different nutrient media with the fluid yielded negative results. In the next 
series of experiments an aqueous solution of trypsin and pancreatin was in- 
jected for the purpose of determining whether the digestive ferments, in 
the event of intestinal perforation, could produce peritonitis. The experi- 
ments established the fact that trypsin acts as a powerful irritant upon the 
peritoneum. Injection of 1 / 2 gramme of trypsin, dissolved in distilled water, 
caused in rabbits a severe hemorrhagic peritonitis, with a copious exudation, 
and death in from four to four and a half hours. In doses of 1 / 4 to 1 / 1Q 
gramme the same local condition was produced, but death did not occur 
until twenty to twenty-four hours after the injection. One-hundredth (0.01) 
of a gramme produced no symptoms. Nutrient media inoculated with the 
products of inflammation remained sterile. Next, the peritoneal cavity was 
infected with plate-cultures of different microbes suspended in sterilized 
water. The first experiments were made with non-pathogenic microbes. 
Four rabbits and one dog were injected with large quantities of a micrococcus 
which was obtained from a plate-culture inoculated with pus; the micrococ- 
cus was exactly similar to the staphylococcus pyogenes albus, for which it was 
first mistaken. Later, it was shown that it was not a pus-microbe, as it did 
not liquefy gelatin. All of the animals recovered. Two rabbits inoculated 
with an entire culture of yellow sarcinas upon agar-agar, mixed with 1 / 10 drop 
of croton-oil, also recovered. The experiments with pathogenic microbes 
always produced positive results. Three series, with three separate microor- 
ganisms, were made next. The staphylococcus pyogenes aureus, grown from 
osteomyelitic pus, was first used. In 17 out of 41 experiments this microbe 
alone was used; in 11 it was mixed with croton-oil, in 6 with trypsin, and 
in 7 with agar-agar. In all cases where pure cultures were used peritonitis 
was produced, the type varying according to the number of microbes used. 
The same microbes could be cultivated upon proper nutrient media from the 
different inflammatory products. In hardened specimens of the inflamed 
peritoneum, stained with different coloring agents, the microorganisms could 
be seen in the lymph-spaces. The suppurative type of peritonitis thus arti- 
ficially produced became more apparent the longer life was prolonged. An 
entire agar-agar culture of the bacillus pyocyaneus caused death from septic 
peritonitis in from twenty-four to forty-eight hours. One-fifth of this quan- 
tity proved harmless. The next series of experiments was made to ascertain 
the cause of peritonitis after intestinal perforation. The fresh intestinal con- 
tents of a healthy animal, just killed, were divided into three parts, one of 
which was at once injected into several rabbits, without filtration, in doses of 
1 syringeful. The second portion was filtered, and of the filtrate from 2 to 



344 PRINCIPLES OF SURGERY. 

3 syringefuls were injected into each rabbit. The third portion was ster- 
ilized, according to TyndalPs direction, for eight days, and then 1 syringeful 
was injected into the abdominal cavity of each animal. The results were as 
follow: Four rabbits died of fibrinous, suppurative peritonitis from the in- 
jections with the first portion. Four rabbits injected with the filtered faeces 
recovered, as did one animal inoculated with the sterilized portion. This 
author maintains that the fibrinous form of peritonitis is the least dangerous, 
as the layers of fibrin tend to limit the entrance of microbes into the circula- 
tion, while they also retard the local diffusion of the injection. The fibrino- 
suppurative variety is the next least dangerous form, while in the most rap- 
idly fatal cases of septic peritonitis the local lesion is not characterized by 
any macroscopical tissue-changes. Putrescible substances, when injected 
in small quantities, were rapidly absorbed without producing peritoni- 
tis; but when the quantity injected was large, and insufflation of unfil- 
tered air was practiced at the same time, peritonitis, with putrefaction and 
death from septic intoxication, occurred. Grawitz proved that saprophytic 
bacteria, when injected into a normal peritoneal cavity, were promptly de- 
stroyed and absorbed. In cases in which the injection was made into a peri- 
toneal cavity which had previously undergone alterations by injury or dis- 
ease, or in which the quantity of fluid was too great for speedy absorption, 
symptoms of intoxication, as described by Weber, resulted; but these symp- 
toms were unaccompanied by suppurative peritonitis. A healthy peritoneal 
cavity has also been found capable of disposing of a limited quantity of pure 
cultivations of pus-microbes, the microbes being removed by absorption and 
destroyed in the circulation or eliminated through the excretory organs. But 
when pyogenic organisms are introduced into an abdominal cavity, in which 
the absorptive capacity of the peritoneum has been diminished or suspended 
by antecedent pathological conditions, suppurative peritonitis is the usual 
result. When pus-microbes are introduced in large quantities, even into a 
healthy peritoneal cavity, the preformed toxins, by their chemical action, so 
alter the tissues that the process of absorption is impaired, and suppurative 
peritonitis again results in consequence of the retention of pus-microbes in 
tissues prepared for their pathogenic action. 

Einne is of the opinion that, on account of the rapidity with which ab- 
sorption takes place in the peritoneal cavity, the peritoneum, when in a nor- 
mal condition, is almost immune to infection with pus-microbes. He in- 
jected from 30 to 35 cubic centimetres of a pure culture of pus-microbes, 
suspended in sterilized water, into the peritoneal cavity of healthy animals, 
and never succeeded, in this manner, in producing peritonitis. He had no 
better success with injections of a mixture of a gelatin culture of staphylo- 
coccus pyogenes aureus and a turbid bouillon culture of the same coccus. 
He also made daily injections with a putrid fluid, to which was added a cult- 



SUPPURATIVE PERITONITIS. 345 

are of the staphylococcus pyogenes aureus, without producing peritonitis. 
The experiments, as a rule, were made on dogs, although, in several instances, 
rabbits, guinea-pigs, and white rats were used. He believes that the differ- 
ence in the results obtained by him and Grawitz, as compared with Pawlow- 
skv, consists in the nature of the abdominal wound. Pawlowsky made an 
incision down to the muscles and then perforated the abdominal w r all with a 
blunt trocar; while he and Grawitz used a sharp, hollow T needle for making 
the intraperitoneal injection. To prove that his injections reached the peri- 
toneal cavit}', he added coal-dust to the fluid, which he found at the post- 
mortems as fine particles clinging to the peritoneal surface. 

Clinical and Bacteriological Studies. — Peritonitis caused by infection 
from without through a penetrating wound or after abdominal operations is 
generally due to the presence of the ordinary pus-microbes. Peritonitis re- 
sulting from intraabdominal infection, intestinal perforation, or rupture of 
an intraabdominal abscess, on the other hand, is most frequently caused by 
infection with the colon bacillus with or without mixed infection with pus- 
microbes. Frankel found the streptococcus pyogenes in a great variety of 
puerperal diseases, especially in cases in which the local affection implicated 
the lymphatic vessels. In such cases the microbes found entrance into the 
pelvic tissues from abrasions or ulcers in the vagina, and by extension of the 
inflammatory process the broad ligaments and the peritoneum are success- 
ively involved; after the peritoneum has once been reached rapid diffusion 
takes place, and, finally, the diaphragm and pleura are implicated in the same 
process, and the microbes reach the blood and cause sepsis and pyaemia. 

In suppurative peritonitis without the existence of a direct communica- 
tion with the external surface or the intestinal canal, we must take it for 
granted that pus-microbes may have entered the peritoneal cavity through 
the Fallopian tubes, through slight defects of the intestinal mucous mem- 
brane, and from here through the lymphatic channels into the peritoneal 
cavity, or through a minute perforation the existence of which cannot be 
demonstrated during life and often not at the post-mortem examination, or, 
finally, localization of pus-microbes from the blood in the capillaries of the 
peritoneum. Weichselbaum has shown that peritonitis is not always caused 
by pus-microbes, as has been heretofore believed, as he found the diplococcus 
of pneumonia unaccompanied by any other microorganisms in 3 cases of peri- 
tonitis. In 1 case peritonitis and pneumonia existed at the same time; in 
the other double pleuritis followed the peritonitis; but in the last case peri- 
tonitis was undoubtedly primary, and, in the absence of any other microbes 
in the products of the inflammation, must have been caused by the diplo- 
coccus of Friedlander. In another case following rupture of the spleen in 
the course of typhoid fever he obtained from the exudate a pure culture of 
the typhoid bacillus. Frankel made a bacteriological study of 31 cases of 



346 PRINCIPLES OF SURGERY. 

peritonitis, with the following result: Bacillus coli communis, nine times; 
streptococci, seven times; bacillus lactis aerogenes, twice; micrococcus pneu- 
moniae crouposse, once; staphylococcus pyogenes aureus, once. In 3 cases 
the bacillus coli communis was present in association with other bacilli, and 
in 4 cases the bacteriological examination yielded a negative result. There 
can be no doubt that septic peritonitis may be caused by pathogenic microbes 
which — at present at least — are not classified with the pus-microbes; but sup- 
purative peritonitis can have no other bacteriological cause, and in most cases 
of septic peritonitis infection with pus-microbes can be demonstrated by 
clinical evidences as well as bacteriological and experimental demonstration. 

Difference between Plastic and Suppurative Peritonitis. — The greatest 
clinical difference between simple or plastic peritonitis produced by trauma 
or chemical irritants and septic or suppurative peritonitis consists in the cause 
and extent of the inflammation. Plastic inflammation produced by aseptic 
causes remains limited to the seat of trauma or chemical irritation, and does 
not extend much beyond the surface-area to which the stimulus is applied; 
while septic peritonitis is always characterized by its progressive character, 
as the cause upon which it depends is reproduced within the peritoneal cav- 
ity. A plastic peritonitis is attended by febrile disturbances, caused by the 
introduction into the circulation of the products of coagulation-necrosis or 
metabolic tissue-changes; in septic peritonitis the general symptoms are 
produced by the entrance of pus-microbes into the general circulation and 
their toxins, both of which are also reproduced in the blood and other organs 
of the body in which secondary localization may take place. 

The Cause of Suppurative Peritonitis. — Experimental research has dem- 
onstrated that in the causation of suppurative peritonitis two conditions 
must be present at the same time: 1. Pyogenic bacteria. 2. A wound of the 
peritoneal surface, or antecedent pathological conditions which diminish the 
absorptive capacity of the peritoneum. The microbic cause is the essential 
etiological factor, as without it the other conditions would not result in this 
form of peritonitis. If pus-microbes are introduced into the peritoneal 
cavity in sufficient quantity suppurative peritonitis is produced, as the pre- 
formed toxins create the indirect etiological conditions. A number of bac- 
teria which at present are not classified with the pus-microbes ma}^, under 
certain favorable conditions, manifest pyogenic properties; and thus, when 
introduced into a peritoneal cavity predisposed to suppuration, cause an at- 
tack of suppurative peritonitis. Thus we have seen that Weichselbaum has 
found the diplococcus of pneumonia in the inflammatory product of three 
cases of peritonitis, and as no other microbes were present it is reasonable to 
assume that suppuration was caused by this microbe. In serous cavities gon- 
orrhceal pus produces, as a rule, a circumscribed abscess. Sinclair, in his ex- 
cellent monograph on "Gonorrhoea! Infection in Women/' after describing 



SUPPURATIVE PERITONITIS. 347 

the gonorrhoea] infection from the vagina, says: "The proper character and 
the result of the pathogenous activity of the gonorrhceic microbes are there- 
fore seen, pure ami unadulterated, in the tube. They cause purulent inflam- 
mation of the mucous membrane, but the surrounding connective tissue re- 
mains free from them. The gonorrhceic tubal pus is evacuated into the peri- 
toneum, and, whereas in other conditions the bursting of an abscess into the 
abdominal cavity is followed by the gravest consequences, in this case the 
whole process terminates with a circumscribed inflammation, encapsuling the 
exuded pus. The cause of this difference is the varying pathogenic value of 
the organisms which are contained in the pus. A puerperal pelvic cellulitic 
abscess, bursting into the peritoneum, causes general peritonitis, because it 
contains pyogenous streptococci, which rapidly multiply in serous cavities 
and are capable of exerting the most deleterious effects. Gonorrhceal tubal 
pus cannot do this; its microbes do not find in the peritoneum conditions 
for their increase to the same extent; the pus, therefore, acts as an aseptic 
foreign body, becomes encapsulated, and is finally absorbed. Practically, it 
is well known that when gonorrhceal infection extends from the Fallopian 
tubes to the peritoneum by leakage of pus into the peritoneal cavity from 
the peritoneal extremity of the tribe, or rupture of a pus-tribe, the result is 
a circumscribed suppurative peritonitis, with the formation of a circum- 
scribed abscess." 

Wertheinr's investigations have shown that the gonococcus can set up a 
peritonitis in animals whose mucous membranes are refractory to the action 
of this microbe. From this it follows that the gonococcus will produce peri- 
tonitis in man, whose mucous membranes are very susceptible to gonorrhceal 
inflammation. He has also demonstrated that the gonococcus can penetrate 
pavement as well as cylindrical epithelium. Under certain favorable circum- 
stances it also gains entrance into the lymphatics. 

That encapsulation of gonorrhceal pus does not invariably follow gonor- 
rhceal infection of the peritoneal cavity is well shown by a case reported by 
Loven, which is by no means an isolated one. The source of infection could 
not be learned in this case, but the diagnosis of gonorrhceic ascending in- 
fection was positive. The disease commenced as an ordinary vulvo-vaginal 
blennorrhcea, which consecutively extended to the uterus, Fallopian tubes, 
and terminated in pelvic and diffuse peritonitis. It is possible that in this 
particular case a secondary infection with pus-microbes had taken place, as, 
at the necropsy, chain cocci were found in the peritoneal cavity. The rela- 
tion of the streptococcus of erysipelas to peritonitis will be considered in the 
chapter on "Erysipelas." Abdominal surgeons are very well aware of the 
clinical fact that septic or suppurative peritonitis, after laparotomy, is more 
prone to develop if fluids, and especially blood, are allowed to remain in the 
abdominal cavity; and consequently resort to a careful toilet of the cavity, 



348 PKINCIPLES OF SURGERY. 

and, if there is any reason to expect a reaccirmulation, to drainage. Fluid in 
the peritoneal cavity except saline solution prevents the removal of the 
pus-microbes by absorption, and if they remain they multiply and cause 
peritonitis. For years it has been customary to resort to the use of opium 
in the prevention and treatment of peritonitis, until Tait showed the fallacy 
of such treatment and recommended cathartics. The treatment of incipient 
peritonitis by a brisk saline cathartic is now generally practiced, and the re- 
sults have been exceedingly satisfactory. What is the modus operandi of 
saline cathartics in the prevention of diffuse septic peritonitis? The most 
rational answer to this question is that a brisk saline cathartic promotes ab- 
sorption of fluids from the peritoneal cavity, and by so doing removes the 
indirect causes of peritonitis, and, at the same time, favors the elimination 
of pyogenic microbes. Intraabdominal wounds not covered with peritoneum 
are potent factors in the development of peritonitis in an abdominal cavity 
which is not absolutely aseptic, as the raw surfaces furnish a considerable 
quantity of wound-secretion, on the one hand, and, on the other, diminish 
the absorptive capacity of the peritoneum. This cause of peritonitis should 
be eliminated, as far as possible, in all intraabdominal operations, by avoid- 
ing unnecessary injury to the peritoneum, and by covering denuded surfaces 
with this membrane wherever it can be done. Another indirect cause of peri- 
tonitis is intestinal obstruction. The intestine above the seat of obstruction 
becomes dilated, congested, softened, and, in consequence of these changes, 
permeable to pathogenic microbes, which are always present in the intestinal 
canal under these circumstances. 

Alapy has made a series of experiments in Weichselbaum's laboratory 
to ascertain if pathogenic microbes could pass through the healthy stomach 
into the intestines. He experimented with pus-microbes and the streptococ- 
cus of erysipelas. From these experiments he came to the conclusion that 
the virulence of these microbes is destroyed in a healthy stomach, but when 
the gastric secretion has suffered diminution of acidity, or has become alka- 
line, the microbes do not lose their pathogenic properties, and pass into the 
intestines in an active condition. In cases of intestinal obstruction the phys- 
iological functions of the stomach are disturbed, and conditions are created 
which preserve the virulence of pathogenic microorganisms on their way 
into the intestinal canal. The immediate cause of death in many cases of 
intestinal obstruction is diffuse septic peritonitis. In the different forms of 
perforative peritonitis the disease is caused by the escape of fluids containing 
pyogenic bacteria, and the type and gravity of the disease are greatly modified 
by the amount of fluid which enters the peritoneal cavity and the number of 
microbes which it contains. Perforation of a typhoid or tubercular ulcer is 
always a grave occurrence, as the fluid which escapes is usually considerable 
in quantity and contains numerous pathogenic microbes. Perforating ulcer 



SUPPURATIVE PERITONITIS. 349 

of the stomach is more frequently followed by circumscribed plastic peri- 
tonitis, which shuts out the general peritoneal cavity. Perforation of the 
appendix vermiformis is followed as often by circumscribed suppurative peri- 
tonitis as by diffuse septic peritonitis. The same can be said of perforation 
of the gall-bladder. 

Symptoms and Diagnosis. — Diffuse septic peritonitis spreads over the 
entire peritoneal cavity almost with lightning speed. The first symptoms 
are those of shock. If the disease follow an abdominal section, it is often 
difficult to determine whether the conditions presented are due to shock or 
diffuse peritonitis, as the latter may set in in a few hours after the operation 
and prove fatal within twenty-four hours. The temperature is variable. It 
may remain normal or become even subnormal, or it may at first be only 
slightly increased and gradually reach 102° to 104° F. Vomiting and diar- 
rhoea are frequently conspicuous symptoms. In other cases the symptoms 
point to intestinal obstruction. In extensive plastic peritonitis the immob- 
ilization of a considerable portion of the small intestine may give rise to 
persistent vomiting and absolute constipation. Again, arrest of the faecal 
circulation may be caused by the tympanites alone, while perforative peri- 
tonitis is attended by a local and general shock, which causes intestinal 
paresis through the inhibitory action of the sympathetic nerves. Heusner 
has observed that perforative peritonitis gives rise to disturbances simulating 
intestinal obstruction by arresting intestinal movements. He narrates the 
histories of 2 cases of this kind in which the symptoms of intestinal obstruc- 
tion were so prominent that laparotomy was performed. In both cases per- 
forative peritonitis, but not occlusion, was found. Henrot, in his classical 
monograph on "Pseudostrangulation," describes a number of cases of per- 
foration of the gall-bladder and the processus vermiformis, where the symp- 
toms during life had pointed so strongly to the existence of intestinal ob- 
struction that a wrong diagnosis was made by able clinicians. He also calls 
attention to those cases of paralytic obstruction which are often observed 
after herniotomy, and in cases of strangulation of the appendix vermiformis 
and testicle. The intestinal paresis, where it is not the result of inflamma- 
tion, must be looked upon as a reflex symptom. 

Physical signs and symptoms are sometimes utterly inadequate to dis- 
tinguish between acute intestinal obstruction and diffuse peritonitis. In 
differentiating between these two conditions it must be remembered that, in 
the absence of a swelling, absolute constipation and faecal vomiting are the 
most characteristic symptoms of obstruction, and that in peritonitis the pain 
is severe and continuous, with diffuse tenderness, tympanites, and absence of 
visible intestinal coils. In mechanical obstruction of the bowels the tem- 
perature is, as a rule, not above normal unless complications have set in; 
while in peritonitis a rise in temperature is the rule, although in some of the 



350 PEINCIPLES OF SUBGEKY. 

gravest cases it is subnormal. Many cases of alleged recover}' from intestinal 
obstruction without operation undoubtedly were cases of a dynamic obstruc- 
tion, and the recovery was either entirely spontaneous or facilitated by means 
which assisted in the restoration of peristaltic action. In 1851 a patient was 
admitted into Dupuytren's ward with well-marked symptoms of acute intes- 
tinal obstruction. This eminent surgeon gave it as his opinion that without 
an operation a fatal termination was inevitable, but the patient objected to 
the operation and was transferred to another ward, where he recovered in 
three days under the use of simple cathartics. 

Numerous similar cases could be cited in illustration of the difficulty 
of differentiating in all cases between mechanical occlusion and a dynamic 
obstruction. In cases of perforative peritonitis and peritonitis with putre- 
faction the presence of gas in the free peritoneal cavity gives rise to an im- 
portant physical sign. In tympanites from peritonitis without perforation 
and intestinal obstruction, the distended intestines push the liver in an up- 
ward direction; hence, on percussion, the liver-dullness is transferred higher 
up. But, under the circumstances mentioned above, the gas in the free 
abdominal cavity occupies the space between the liver and the chest-wall; 
consequently the liver-dullness has disappeared and the space over the organ 
is tympanitic on percussion. One of the most constant signs in peritonitis 
is the small, rapid, compressible pulse. In diffuse peritonitis it usually ranges 
between 120 and 140. In rapidly-fatal diffuse septic peritonitis pain is often 
wanting. In circumscribed peritonitis pain and tenderness are limited to the 
affected region. Tympanites is often a most distressing s} r mptom in circum- 
scribed peritonitis, and may be entirely absent in the most fatal form of 
septic peritonitis. Eigidity of the abdominal muscles is an indication of 
peritonitis, while it is absent in uncomplicated intestinal obstruction. In 
suppurative peritonitis the presence of pus in considerable quantity is indi- 
cated by the physical signs arising from the accumulation of fluid, either in 
the free peritoneal cavity or in a circumscribed space of it. If the pus is not 
confined by adherent intestines and plastic exudation, it will gravitate toward 
the most dependent portion of the peritoneal cavity, and, on this account, the 
area of dullness will vary according to the position of the patient. In cir- 
cumscribed suppurative peritonitis the pus is confined 4 in a limited space by 
adherent abdominal organs and fibrinous exudation, and will then present 
all the signs and symptoms of a deep-seated abscess. To determine the char- 
acter of peritoneal effusion, or of the contents of a circumscribed intraperi- 
toneal inflammatory swelling, it is necessary to resort to an exploratory 
puncture. The needle is inserted at a point where the fluid is in contact with 
the abdominal wall, and, in the circumscribed form of peritonitis, in a place 
where the puncture can be made without traversing the free peritoneal cavity. 

Treatment. — In perforative peritonitis cathartics are absolutely con- 



SUPPURATIVE PERITONITIS. 351 

traindicated, as increased peristalsis would aggravate the existing conditions 
by increasing the extravasation and by preventing limitation of the infection. 
In such cases opium should be administered to diminish the peristalsis, to 
relieve pain, and to diminish shock. The subsequent safety of the patient 
will rest on an early radical treatment by laparotomy. Unless the location 
of the perforation can be ascertained beforehand, the incision should be made 
in the median line. In cases of perforation of the appendix vermiformis an 
incision extending from the middle of Poupart's ligament to a point half- 
way between the anterior-superior spinous process of the ilium and umbilicus 
will secure most direct access to the seat of perforation. Perforating tuber- 
cular and typhoid ulcers are found most frequently in the ileo-caecal region. 
If, on opening the abdominal cavity, the perforation cannot be readily found, 
it is better to resort to rectal insufflation of hydrogen-gas at once, which will 
show with unfailing certainty not only that a perforation exists, but also its 
exact location. In multiple perforations the same diagnostic test is almost 
indispensable, as it will avoid the great mistake of leaving a perforation un- 
sutured. The perforations are treated in the same manner as an incised 
wound. Care must be taken to suture the opening in a direction that will 
interfere the least with the lumen of the intestine. Tine aseptic silk should 
always be used in preference to catgut; at least two rows of sutures must be 
applied. 

After suturing the perforation the abdominal cavity is washed out freely 
with warm saline solution. Drainage in these cases must never be omitted, 
as the operator has no assurance that the peritoneal cavity has been rendered 
perfectly aseptic. Laplace has recently recommendecr continuous irrigation 
with saline solution in the treatment of diffuse septic peritonitis, and this 
suggestion has much to recommend it to an extensive trial. If the intestines 
are much distended and paretic, evacuation through one or more incisions 
and injection into the bowel of a saturated solution of sulphate of magnesia, 
as suggested by McCosh, should be practiced. A threatened septic peritoni- 
tis after laparotomy can often be aborted by giving half an ounce of sulphate 
of magnesia, dissolved in a glassful of water, upon the appearance of the first 
symptoms. The administration of the same drug in half-drachm or drachm 
doses every half-hour as recommended by Byford is preferable to a single 
large dose. The action of the saline cathartic can be hastened and its bene- 
ficial effects increased by the administration of a turpentine enema. After 
the bowels have been moved thoroughly opium can be given in sufficient 
doses to relieve pain. If the symptoms do not subside under this treatment, 
the abdominal wound is opened sufficiently to permit free irrigation with 
salicylated water, and a Keith drain is inserted, loosely packed with iodoform 
gauze, and a copious hygroscopic sterile dressing applied. Many surgeons 
of the present time doubt the occurrence of peritonitis without a local source 



352 PRINCIPLES OF SURGERY. 

of infection, and there can be no doubt that so-called spontaneous peritonitis 
without such a local focus is exceedingly rare, but its existence cannot be 
denied. If suppuration in a joint, in the pleural cavity, or in the pericar- 
dium can occur without such a direct local cause, there is no reason why 
suppurative peritonitis should not, at least in exceptional cases, have a similar 
origin. A locus minoris resisteniice of a non-suppurative type in any part 
of the peritoneal cavity can determine localization of pus-microbes here as 
well as in any other part of the body. In opening the abdomen for the 
evacuation of pus the surgeon must look for a primary lesion; but he will 
not always find it, as it is not invariably present. Diffuse septic and suppura- 
tive peritonites are seldom, if ever, cured by laparotomy. Localized suppura- 
tive peritonitis brought about by curable causes is amenable to successful sur- 
gical treatment. An operation is always indicated as soon as the presence of 
pus is ascertained. Delay is dangerous in these cases, as the delicate walls, 
composed of plastic exudation, may yield to the pressure, and the extravasa- 
tion of pus infects a new portion of the peritoneal cavity, or perhaps its 
entire extent. In circumscribed suppurative peritonitis the incision is to be 
made at a point where the pus is in contact with the abdominal wall. The 
abdomen is to be opened by a careful dissection, and if the incision lead 
directly into the pus-cavity this is drained and washed out with saline solu- 
tion or a weak antiseptic solution. If, on cutting through the peritoneum, 
no pus is found, and the peritoneal cavity has been opened, it is not safe to 
evacuate the pus until the cavity has been shut out by suturing the 
abscess-wall to the parietal peritoneum, or packing the wound for a few 
days with iodoform gauze, and postponing the opening of the abscess until 
firm adhesions have formed between the margins of the wound and the sur- 
face of the abscess-wall. This method of operating in two stages must be 
frequently resorted to in the treatment of pelvic abscess, abscess of the liver, 
and empyema of the gall-bladder. If the primary disease which has caused 
the intraperitoneal suppuration can be discovered, this must receive special 
attention. In circumscribed suppurative peritonitis in the right iliac region 
caused by perforation of the appendix vermiformis the appendix must be 
looked for, and when found perforated it is excised near its attachment to 
the caecum, after tying its base with a fine-silk ligature, if this can be done 
without risk of exposing the free peritoneal cavity to infection, otherwise the 
abscess is simply drained. All operations for suppurative peritonitis are to 
be conducted upon rigid aseptic principles, and aseptic measures are to be 
followed without relaxation during the entire after-treatment. As patients 
suffering from peritonitis are always greatly debilitated from the effects of 
the disease as well as from lack of solid food, which, for well-founded reasons, 
must be withheld, every effort should be made to sustain strength by the 
systematic administration of liquid nourishment and alcoholic stimulants. 



SUPPUB \ DIVE im:i;i iom lis. 353 

A 1. solute rest must be enforced for the purpose of limiting the extension of 
the disease and with a view of aiding the process of repair. Suspension 
of stomach-feeding is one of the mosi important things in securing intestinal 
rest. 






CHAPTER XIV. 

Septicemia. 

Septicemia, septaemia, sepsis, are synonymous terms used to designate 
a general febrile affection caused by the introduction into the circulation of 
the products of fermentation or putrefaction, and which is characterized by 
definite blood-changes, a typical series of inflammatory processes, a peculiar 
group of nervous symptoms and critical discharges. Clinically, and prob- 
ably etiologically, it is closely related to pyaemia. The older pathologists en- 
tertained the belief that in cases of septicaemia the blood itself was the seat 
of putrefactive changes. At present it is generally conceded that it results 
from the introduction into the circulation of septic microorganisms or their 
toxins. The symptoms do not suffice for a full characterization of the dis- 
ease, but the specific infection is the integral and essential factor. 

BACTERIOLOGICAL RESEARCHES. 

Septic processes were among the first to excite interest in the part played 
by microorganisms in disease. Although some of the best pathologists have 
been diligently investigating this subject for years, we still remain in the 
dark concerning its true etiology and its relation to other infective processes. 
True sepsis is now regarded as a general infection from some local source, un- 
attended by any gross pathological changes. Some writers have claimed the 
etiological difference between septicaemia and pyaemia to be a quantitative and 
not a qualitative one, while others maintain that pyaemia is a specific disease 
sui generis-, and that it is in nowise related to sepsis. There can be no doubt 
that true progressive sepsis, if not invariably, is, at least frequently, caused by 
the same microbes which produce pyaemia. As we have seen in the foregoing 
chapter, the same microbes, when introduced into the peritoneal cavity, may 
either cause a circumscribed suppurative peritonitis or a diffuse septic peri- 
tonitis, with all the clinical features of progressive intoxication. The first 
reliable investigations into the microbic origin of sepsis were made by Rind- 
fleisch in 1866, and, somewhat later, by Klebs, Recklinghausen, Waldeyer, 
and Hueter. Rindfleisch found bacteria in abscesses, while the researches of 
Klebs initiated a new era in the etiology of septic diseases. Klebs differen- 
tiated between septicaemia and pyaemia, although he claimed that putrid in- 
toxication and septic infection were the same. In the tissues altered by septic 
processes, and in the lymph-spaces and in the blood, he found a microbe, a 
round coccus, isolated and in groups, which he termed micro spor on septicum. 

Septicaemia in Mice. — One of the best descriptions of true progressive 

(354) 



BACTERIOLOGICAL RESEARCHES. 355 

septicaemia that*has ever been given is by Koch on septicaemia in mice. He 
usul the sauu 1 method which was followed by Coze, Feltz, and Davaine. He 
injected putrid fluids, decomposed blood, putrefying blood, under the skin 
in mice. He found that the virulence of these fluids was attenuated by age. 
Blood that had putrefied only for a few days, in 5-drop doses, killed a mouse 
within a short time. In this case marked symptoms were observed in the 
animal immediately after the injection. 

The animal became very restless, running about constantly, but showing 
great muscular prostration and uncertainty in all its movements; it refused 
food, the respiration became irregular and slow, and death took place within 
eight hours. The greater portion of the fluid injected was found, after death, 
not to have been absorbed. No inflammation at the seat of injection. No 
macroscopical pathological changes were found in any of the internal organs. 
Blood taken from the right auricle and injected into another mouse produced 
no symptoms. Xo bacteria could be found in the blood or any of the internal 
organs. Koch concluded that death was not caused by bacteria, but by the 
introduction into the circulation of a preformed poison contained in the 
putrid fluid, as when smaller doses were used the symptoms of intoxication 
were less marked, and when the quantity was reduced to 1 drop the animal 
often recovered without manifesting any morbid symptoms. About one- 
third of the animals which had received 1 or 2 drops of the fluid subcutane- 
onsly remained well for about twenty-four hours, when an increased secretion 
from the conjunctiva was observed; at the same time the animal showed 
signs of great muscular weakness. It then ceased to take food; its respira- 
tions became slower, prostration became more and more marked, and death 
came on almost imperceptibly. After death the animal remained in the sit- 
ting posture with its back strongly bent. Death occurred in from forty to 
sixty hours after inoculation. The only post-mortem change noticed was a 
slight subcutaneous oedema at the point of injection, and this w T as not con- 
stantly present. 

Koch then experimented with the cedema-fluid and blood of mice that 
had died of sepsis, 1 / 10 drop of which was injected into another mouse, when 
exactly the same symptoms and result were produced in the latter animal, 
after the same lapse of time and in the same order as in the former. 

From this second animal a third was infected in like manner, with 
identical results. Successive inoculations proved that the virus could be 
propagated indefinitely from animal to animal without losing its virulence. 
He could communicate the disease with certainty by passing the point of 
a scalpel, which had been in contact with the infected blood, over a small 
wound of the skin. The blood of the animals which became ill after injec- 
tion of 1 to 10 drops of putrefying blood was found to contain, as a rule, dif- 
ferent varieties of bacteria in small numbers, micrococci, and large and small 



356 



PRINCIPLES OF SURGERY. 



bacilli. If, however, it died after inoculation with putrefying or septicemic 
blood, small bacilli alone appeared in the blood. This result was- constant, and 
the bacilli were always in large numbers. These bacilli lie singly or in small 
groups between the red blood-corpuscles. One can often see the bacilli in 
septicemic blood attached to each other in pairs, either in straight lines or 




Fig. 130.— Vein of the Diaphragm of a Septicsemic Mouse. A, nuclei of the vascular 
wall; B, septicaemic bacilli; C, white blood-corpuscles which have become transformed 
into masses of bacilli; D, capillaries opening into vein. X 700. (Koch.) 1 

forming an obtuse angle. In some cases Koch has also seen spores in the 
bacilli. Their relation to the white corpuscles is peculiar. They penetrate 
into these and multiply in their interior. 



1 Figs. 130, 132, and 133 are copied from "Traumatic Infective Diseases," by permission 
of the New Sydenham Society, London. 



BACTERIOLOGICAL RESEARCHES. 357 

Microscopical examination of the tissues at the point of inoculation 
Bhowed that the bacilli entered the capillary blood-vessels, where they caused 
such extensive alterations as to give rise to extravasation of numerous red 
blood-corpuscles. They were never found in the lymphatic vessels. Within 
the blood-vessels they are almosl always arranged with their long axis in the 
direction of the blood-current. In the capillaries the bacilli congregate, par- 
ticularly at the point of division, but never cause complete obstruction. 
Rabbits and field-mice proved immune to inoculations with the septicemic 
blood of the domestic mouse. The bacillus of Koch's septicemia can be 
cultivated upon a mixture of aqueous humor and gelatin, or of gelatin, pep- 
tone (1 per cent.), salt (0.6 per cent.), and sodium phosphate in sufficient 
quantity to render the mass alkaline in reaction. The bacilli grow well upon 
this mixture, and by repeated and rapid division form peculiar branched 
series. 

Septicaemia in Rabbits. — Although Koch w^s unable to produce sep- 
ticemia in rabbits, either by injections or inoculations of septicemic prod- 
ucts from the domestic mouse, he caused the disease artificially by injecting 




Fig. 131.— Bacillus of Mouse-septicaemia. Single Colony in Nutrient Gelatin. 
X 80. (Fliigge.) 

a putrid infusion of meat. In these cases the injection produced extensive 
suppuration, with putrefaction, and the animals died in three days and a 
half. Various bacteria were found in the inflammatory product. At the 
border of the local inflammation the connective tissue was infiltrated with a 
turbid, serous fluid, which contrasted strongly with the brownish, offensive 
pus. In this oedema-fluid only cocci of an oval form were found. In the 
blood similar microbes were discovered, though only in small numbers. 
Some of the small veins in the spleen and kidneys were seen to be com- 
pletely blocked with the same microbe. 

Two drops of the oedema-fluid were injected under the skin of the back 
of a second rabbit. The animal died in twenty-two hours, and here, in the 
vicinity of the injection, not a trace of suppuration could be found. Hemor- 
rhagic extravasations were present in the inflamed cedematous connective tis- 
sue. Xo alterations were found in the heart and lungs. In this animal the 
oval micrococci were alone present in the oedema-fluid. Micrococci were also 
found in the capillary vessels in different organs; in some of them the lumen 
of the vessels was completely blocked. In the capillary vessels surrounding 



358 



PRINCIPLES OF SURGERY. 



the intestinal glands numerous obstructing masses of the bacilli were pres- 
ent. At many points these were so extensive that branching accumulations 
were seen consisting entirely of these organisms. This microbe was never 
seen to inclose blood-corpuscles, and, as they did not cause coagulation of 
the blood, embolism was never observed. The virulence of the bacillus was 
not increased by successive inoculation with infected blood from animal to 
animal. 




Fig. 132. — Glomerulus of a Septicemic Rabbit. A, capillary loop with oval micro- 
cocci spread out like a membrane; B, micrococci deposited on the walls of a capillary 
vessel; C, loop completely filled with micrococci; D, individual micrococci in a capil- 
lary vessel near a glomerulus. X 700. {Koch.) 



The bacillus now under consideration appears to be closely allied or 
identical with that of Davaine's septicaemia, which was first produced by in- 
jecting rabbits with putrid ox-blood. The two diseases are distinguished in 
that Davaine's septicaemia is easily transmissible to guinea-pigs, but not to 
birds; while mice, pigeons, fowls, and sparrows are very susceptible to the 
bacillus of septicaemia in rabbits, discovered by Koch, but guinea-pigs, dogs, 
and rats resist. Hueppe believes that this microbe is not a bacillus, but a 
coccus in a state of elongation; and Gaffky, Schuetz, Kitt, Salmon, Fliigge, 



BACTERIOLOGICAL RESEARCHES. 



359 



and Baumgarten classify it with the bacilli. It readily stains in aniline solu- 
tions. Upon sterilized gelatin it grows in the form of clear, finely-granular 
drops, which, when they become confluent, form a culture which appears as a 
grayish-white film with jagged borders. Liquefaction of the gelatin never 
takes place. It can also be cultivated upon agar-agar, coagulated blood- 
serum, and potato. Gaffky investigated Davaine's septicaemia experiment- 
ally. He procured the infection by using water from a stagnant rivulet, and, 
by continually controlling the experiments with the microscope, using Koch's 
methods, and working only with pure cultures, he was able to prove beyond 




Fig. 133. — Capillary Vessels Surrounding the Intestinal Glands of 
Septicemic Rabbit. X 700. (Koch.) 



a doubt that the theories of progressive virulence of bacteria were untenable- 
He showed that the highest degree of virulence was already attained in the 
second generation. He pointed out that the fallacious conclusions were due 
to impurification in the experiments, and that when the proper precautions 
are taken, in the process of sterilization, to prevent the admixture of other 
microorganisms, the introduction of one kind always produces in the same 
animal the same definite result. 

The most interesting conclusions to be drawn from the experiments in 
Koch's laboratory point to the fact that septicaemia is only a general term 
which includes a number of morbid processes, and this is well illustrated by 



360 PRINCIPLES OF SUEGEEY. 

the injection into the tissues of the "vibriones septiques" of Pasteur. Surface 
inoculations with these bacilli produce no effect; their pathogenic influence 
became only evident after injections into the subcutaneous connective tissue. 
Gaffky found that this bacillus grows most readily upon potato. Koch ap- 
plied to the condition produced by this bacillus the term "malignant 
oedema." 

Malignant (Edema. — The bacillus of malignant oedema was described by 
Koch as the cause of a fatal disease in guinea-pigs and rabbits. The same 
bacillus was described by Pasteur as "vibrion septique." Kecently, this dis- 
ease has been found also in some of the domestic mammalia and in man. 
The bacillus resembles morphologically the bacillus anthracis. 

Usually, two or three bacilli are joined end to end, and thus form 
straight or curved rods two or three times the length of one bacillus. When 
stained, the threads present a granular appearance, from the unequal dis- 
tribution of the staining: material. 



7 @ 

Fig. 134. Fig. 135. 

Fig. 134.— Bacillus of Malignant (Edema. A, from the spleen of a guinea-pig; 

B, from the lung of a mouse. X 700. (Koch.) 
Fig. 135. — Spore-formation in Bacillus of Malignant (Edema. (Flugge.) 

This bacillus is somewhat narrower than the anthrax bacillus, and when 
stained does not present such a regular, chain-like appearance. Sometimes 
the bacillus is found motile, but not always, while the anthrax bacillus is 
always devoid of this property. It multiplies by spores, but these appear 
only in the middle and at the ends. 

This microbe is anaerobic, and can only be cultivated by exclusion of 
oxjrgen. The bacillus can only grow in the interior of agar-agar, gelatin, or 
coagulated blood-serum, if the needle-puncture on the surface of the nutrient 
medium is hermetically sealed. The growth of the bacillus is attended by the 
formation of gas-bubbles. 

The gas has an intensely offensive odor. Blood-serum is liquefied. The 
temperature of the blood is most favorable to the growth of the bacillus, and 
cultures develop also, but slowly, at a temperature of 18° to 20° C. 

This bacillus is widely diffused, and can be found in almost any putre- 
fying substance. The bacillus of malignant oedema possesses the power of 
peptonizing albumen. It is found in abundance in garden-earth and hay- 




BACTKKHH.OiilCAL RESEARCHES. 



361 



dust. If a small quantity o( either of these substances is inserted underneath 
the skin of a guinea-pig, death is produced within forty-eight hours. The 
most characteristic post-mortem appearance is a diffuse oedema at the point 
of inoculation. The oedema-fluid is a clear, reddish serum, in which can be 
found bubbles of gas and numerous bacilli. The spleen is enlarged, of a 
darker color than normal, but the other organs present no macroscopical 
changes. The bacilli can be found in the parenchyma-fluid of nearly all 
organs, and especially is their number great in the envelopes of the infected 
organs. Mice die in from sixteen to twenty hours after inoculation. Horses, 
sheep, and pigs can be successfully inoculated, while cattle are immune to 
the bacillus. The disease can be communicated from animal to animal by 
implantation of fragments of infected tissue, or by inoculation with 1 or 2 
drops of the oedema-fluid. Surface inoculation is harmless, as the bacillus 





Fig. 136.— Cultures of Bacillus of Malignant CEdema in Gelatin. (Flugge.) 



will not multiply when exposed to atmospheric air. In man malignant 
oedema appears in the form of progressive gangrene with emphysema, (gan- 
grene gazeuse). Eecently, the identity of this disease with malignant oedema 
has been proved by inoculation experiments by Chaveau, Arloing, Brieger, 
and Ehrlich. Animals which have recovered from an attack of malignant 
oedema remain immune to this disease, but prophylactic inoculations have so 
far yielded only, negative results. Chaveau made many experiments on 
guinea-pigs, sheep, and horses by injecting the liquid contents of bullae 
which he found in cases of septic gangrene. In doses of 1 / 5 drop in guinea- 
pigs and from 2 to 4 drops in horses, it produced death in a short time. In 
all cases the necropsy showed, at the point of injection, localized oedema and 
turbid serum in the peritoneal, pleural, and pericardial cavities. In the fluids 
the bacillus could always be demonstrated under the microscope. The disease 
could be reproduced in other animals by inoculation with the serous fluid 



362 PRINCIPLES OF SURGERY. 

contained in any of the serous cavities. The microbe proved less virulent 
when injected directly into the circulation. 

Dominici found that experimental septicaemia caused nucleated red 
blood-cells to appear in the bone-marrow of the infected animals. In ex- 
amining the bone-marrow of human beings the subjects of septic infection, 
he found, besides myeloplaques and many mononucleated cells, a number 
of red blood-corpuscles with a single nucleus. He ascertained that, while 
their occurrence is rare, nucleated corpuscles do appear at times in the cir- 
culating blood in cases of septicaemia. 

PYOGENIC MICROBES AS A CAUSE OF SEPSIS. 

The general symptoms which accompany all suppurative affections rep- 
resent, etiologically and clinically, a form of sepsis, which differs in its in- 
tensity according to the quantity of pus-microbes, or their toxins, which 
reach the general circulation. The slight fever which often attends the de- 
velopment of a furuncle ceases with the removal of the products of inflam- 
mation, while a septic or diffuse suppurative peritonitis results in death in a 
short time from septic infection. The different forms of suppurative inflam- 
mation result in gangrene if the disease prove fatal; the immediate cause of 
death is usually septic infection or putrid intoxication. "Watson Cheyne 
maintains that the microbes of sepsis only grow in loco, and act by producing 
toxins, or, if they occur in the blood, they do not make emboli. 

Vidal reported to the Academie de Medecine de Paris the results of his 
studies of the "forme septicemique pure" in puerperal fever of typhoid type 
without suppuration. In all of the cases in which he made a bacteriological 
examination he found the streptococcus pyogenes, and from this and the 
results of his culture and inoculation experiments he comes to the conclusion 
that it is impossible, in the present state of our knowledge, to distinguish 
between the various forms of streptococci, and that one and the same kind 
can set up any of the various forms of septic infection. Besser has examined 
22 cases of traumatic sepsis, and found microbes of suppuration in every one 
of them. During the patient's life he discovered the microbe (a) in the blood 
in 4 of 16 cases examined; (b) in the pus or fluid discharge from the primary 
focus, in 17 of 17; (c) in the urine, in 3 of 4; and (d) in the sputa, in 3 of 3; 
while after death the microorganism was present (a) in the blood, in 7 of 15; 
(b) in the internal organs, in 16 of 18; and (c) in the pus or uterine dis- 
charges, in 12 of 12. In 6 of 22 cases pus-microbes were simultaneously de- 
tected side by side with masses of bacteria of many other species. In 3 cases, 
however, the streptococcus was found alone, unassociated with any other mi- 
crobe. Besser is of the opinion that the streptococcus of suppuration is the 
most frequent cause of sepsis. Smith isolated and cultivated, from 2 cases of 
puerperal sepsis, a streptococcus which, by inoculation and cultivation ex- 



CLINICAL FOBMS 01 BEPTIC BMIA. 363 

periments, differed from the streptococcus of Fehleisen and the ordinary 
streptococcus of suppuration. 1 [e made a series of gelatin cultures with blood 
taken from the heart. After an interval of two or three days numerous colo- 
nies appeared. Eats inoculated with a pure culture died in from three to four 
Jay-: the same microbe was discovered in their blood. Inoculations were 
also made in the oars of rabbits, and at the end of twenty-four hours a circum- 
scribed redness without tendency to diffusion was apparent, the redness dis- 
appearing in two or three days. Another series of cultures and inoculations 
was made with blood taken from the finger of a woman sick with puerperal 
fever, with similar results. 

From these considerations it becomes evident that the essential bacterial 
cause of septicemia is variable, and that the disease represents a general febrile 
condition, which is brought about by the absorption from a local focus of dif- 
ferent toxins from as many different microbes. As the introduction into the 
circulation of the products of putrefaction is followed by a complexus of 
symptoms which closely resemble what is understood clinically by the term 
septicaemia, and as different microbes have been cultivated from septic pa- 
tients, it would seem that this disease can be produced by any of the microbes 
which, after their introduction into the organism, have the capacity to multiply 
and produce a sufficient quantity of phlogistic toxins to give rise to septic in- 
toxication. 

CLIXICAL FORMS OF SEPTICAEMIA. 

•. 

A clinical description of septicaemia cannot be given without a sub- 
division- of the disease upon an etiological basis. Since the publication of 
Gaspard's researches it is absolutely necessary to make a distinction between 
septic intoxication and septic infection. By septic intoxication is understood 
that form of septicaemia which is caused by the absorption from a local focus 
of a ferment or the products of putrefaction, while the term septic infection 
is limited to those cases where septic microorganisms gain entrance into the 
circulation, and not only exercise their pathogenic properties in the blood, 
but retain their capacity of reproduction in the circulation and distant or- 
gans. Septic intoxication is caused by the absorption of a preformed ferment 
or toxin, which produces the maximum result as soon as it reaches the circula- 
tion, and the symptoms subside with the arrest of further supply and the elim- 
ination of the septic material from the circulation. Septic infection, on the 
other hand, occurs in cotisequence of the introduction into the circulation 
of living microorganisms which multiply with great rapidity in the blood: a 
circumstance which imparts to this form of septicaemia its progressive char- 
acter. Septic intoxication is caused either by the absorption of fibrin- ferment 
or the products of putrefactive bacteria. 

(a) Fermentation Fever. — Fermentation fever (Bergmann), after-fever 



364 PRINCIPLES OF SURGERY. 

(Billroth), aseptic fever (Volkmann), resorption fever, are terms used to 
designate a general febrile disturbance caused by the absorption of the prod- 
ucts of aseptic tissue-necrosis. This, the most simple and harmless of all 
wound complications, appears as a temporary fever soon after an injury or 
operation, and is caused by the absorption of aseptic phlogistic substances. 
Different aseptic inert substances, when injected into the circulation, are 
known to produce a rise in temperature. Bergmann witnessed such a reac- 
tion after intravenous infusion of a physiological solution of salt; Freese, 
after transfusion of blood of healthy animals; and Bergmann, Strieker, 
Albert, and Billroth, after intravenous injections of a considerable quantity 
of well-water. The same effect is produced by intravenous injections of 
water in which fine foreign particles, as flour or finely-pulverized charcoal, 
are suspended. Volkmann and G-enzmer observed a rise in temperature in 
patients soon after the operation was completed and when the wound re- 
mained aseptic throughout, and hence called this form of fever aseptic fever. 
These authors attribute the fever to the reception into the blood of dead tis- 
sue-material. Bergmann devised the term fermentation fever upon the 
theory that the fever is caused by the presence of fibrin ferment in the blood. 

Angerer and Edelberg demonstrated experimentally that this fever 
occurs after transfusion, if the blood transfused contain fibrin-ferment. 
Schmiedeberg attributed the fever to the presence of another blood-ferment 
which he discovered and which he called "histozym." Bergmann and 
Angerer'^ experimental researches show that a fever which resembles the 
fermentation fever almost to perfection can be artificially produced in ani- 
mals by intravenous injections of pancreatin, pepsin, and trypsin. It would 
appear that the albuminoid substances, which are in excess in the blood, 
undergo oxidation by the action of a ferment, and that the chemical changes 
brought about in this manner occasion rise in temperature, while the prod- 
ucts of oxidation are eliminated through the kidneys. Eiedel found, in many 
cases of simple subcutaneous fracture, albumen in the urine during the first 
three or four days, and the urine always contained brown masses, which he 
regarded as products of the red blood-corpuscles. W. Miiller found invari- 
ably, after transfusion of blood, a considerable increase of urates in the urine. 
The occurrence of fever after the introduction of foreign aseptic substances 
into the circulation can only be explained upon the supposition that they 
destroy red and white corpuscles in the blood, and that in this manner fibrin- 
ferment, the cause of the fever, is generated. 

Symptoms and Diagnosis. — Fermentation fever is prone to follow an 
operation or injury if antiseptic solutions are allowed to remain in the wound, 
thereby causing necrosis of the superficial tissues, or where, after closure of 
the wound, parenchymatous oozing gives rise to tension: a local condition 
which forces the products of coagulation-necrosis into the circulation. As 



CLINICAL FOBMS OF BEPTICiEMIA. 365 

not all extravasations of blood give rise to fever, we must take it for granted 
that when fever is not produced its absence is owing either to an absence of 
fibrin-ferment or the existence of local conditions which prevent its absorp- 
tion. From my own observations I am convinced that the amount of ex- 
travasated blood holds no relation whatever to the frequency of its occur- 
rence or its intensity. A small extravasation under high pressure is more 
frequently the cause of fermentation fever than a large blood-clot in a loca- 
tion less favorable to the absorption of fibrin-ferment. Fermentation fever 
makes its appearance within a few hours after an injury or operation, and, 
as a rule, it is not preceded by a chill. The temperature rapidly reaches its 
maximum, which varies from 100° to 104° F., and remains, without much 
variation, in the vicinity of the maximum height, to drop suddenly to nor- 
mal at the end of the first to the third day. The pulse is correspondingly 
increased in frequency during the febrile attack. The sensorium remains 
intact, the appetite is not much disturbed, and none of the subjective symp- 
toms are proportionate to the severity of the febrile disturbance. Patients 
with a high temperature feel so well that, if their wounds permit it, they 
will insist on walking around and will attend to their business, contrary to 
the advice of the attending surgeon. The most important diagnostic feat- 
ures of fermentation fever are its early onset after an injury or operation, and 
its spontaneous subsidence in from one to three days. As the disease is caused 
by the introduction of phlogistic substances from a local focus, and propa- 
gated by intravascular chemical changes, it is uninfluenced by any form of 
medication. The fever subsides spontaneously upon cessation of the primary 
cause, and with the elimination through the kidneys of the products of in- 
travascular chemical changes. As the remaining forms of sepsis usually ap- 
pear at a time when fermentation fever has run its course, the differential 
diagnosis presents no great difficulties. 

The treatment of fermentation fever is entirely of a prophylactic nature. 
The prophylactic measures consist in a careful haemostasis, and in cases 
where parenchymatous oozing, from the nature of a wound or the anatomical 
structure of the tissues, is to be expected, the prevention of the accumulation 
of the primary wound-secretion by efficient drainage. Fermentation fever 
must be included among the septic diseases, as the fibrin-ferment acts as a 
toxic substance in the same manner as the toxins elaborated by septic mi- 
croorganisms. Future research may yet demonstrate that even this, the most 
harmless form of septicaemia, is not an aseptic fever, but that it is caused by 
pathogenic microorganisms, either too few in number or not of sufficient 
potency to produce the graver forms of the disease. 

(b) Sapraemia. — This term was devised by Mathews Duncan to include 
a form of septicaemia resulting from the absorption of the products of putre- 
faction. Sapraemia is the typical form of septic intoxication, as it is always 



366 PRINCIPLES OF SURGERY. 

caused by the introduction into the circulation of preformed ptomaines 
elaborated in dead tissues by putrefactive bacteria. It is closely allied to 
fermentation fever, as the symptoms are never intensified after the removal 
of the primary cause, but, as a rule, subside promptly after this has been 
accomplished. As saprsemia never occurs without putrefaction of necrosed 
tissue, and as putrefaction never takes place without infection with putre- 
factive bacteria, it becomes necessar}^ to consider briefly the microorganisms 
which are known to cause the clinical forms of putrefaction. 

Bacilli of Putrefaction. — The bacilli of putrefaction exercise their 
pathogenic qualities only in dead tissue exposed to the atmospheric air. 
Clinically they are therefore present in the products of coagulation-necrosis, 
or as a secondary infection in tissues destroyed by other microorganisms. 
Most of them possess gasogenic properties. Eosenbach discovered, in differ- 
ent fetid secretions, three forms of bacilli which he designated, respectively, 
bacillus saprogenes 1, 2, 3. 



w 9 y^ 


2 




3 


Fig. 137. 


Fig. 138. 




Fig. 139. 


Figs. 137, 138, and 139.- 


—Bacillus Saprogenes 1, 2, 3. 


962 : 1. 


(Rosenbach.) 



Bacillus Saprogenes 1. — A comparatively-large bacillus, which multi- 
plies by end-spores, which, however, grow only from one end of the bacillus. 

On nutrient agar-agar the bacillus grows in the form of an irregular 
sinuous streak, with a mucilaginous appearance. The bacilli grow readily 
also in blood-serum, and all cultures emit the odor of decomposing kitchen 
refuse. Albumen or meat acted upon by a culture of this bacillus undergoes 
rapid putrefaction if exposed to atmospheric air, but if air is excluded the 
action of the microbes upon these substances is very slight. Cultures injected 
into healthy tissues and joints are harmless. 

Bacillus Saprogenes 2. — This bacillus was isolated by Eosenbach from 
fetid sweat. The rods are shorter and thinner than the preceding ones. 

This bacillus develops very rapidly on agar-agar, forming transparent 
drops, which become gray. The culture yields a characteristic fetid odor, 
similar to the last. Cultures of this bacillus injected into the knee-joint and 
pleural cavity of rabbits caused acute suppurative inflammation and death. 

Bacillus Saprogenes 3. — This bacillus was discovered by Eosenbach in 
the pus of 2 cases of osteomyelitis with septic manifestations complicating 
compound fracture. 



I l l\ [CAL POEMS Ob' BEPTICLffiMIA. 307 

Cultivated on nutrient agar-agar, an ash-gray, almost-liquid culture is 
developed, with a strong, characteristic odor of putrefaction. Injected into 
the knee-joint or abdomen of a rabbit, an opaque, yellowish-green infiltration 
resulted. 

Proteus Vulgaris. — This and the following species have been described 
by Ilauser as present in putrefying meat-infusions, and as being intimately 
connected with the process of putrefaction. As the name indicates, these 
bacteria are capable of changing their form during their development. The 
different species of proteus have been described as coccoid, bacteroid, spindle- 
shaped, and spiralinar, on account of the ever-changing form they assume 
during their growth. The morphology of the proteus vulgaris is very vari- 
able. 













00' 



^h 




Fig. 140. — Proteus Vulgaris. 285:1. Swarming Islets. (Hauser.) 

Many of the rods are actively motile, and cultivated upon nutrient 
gelatin they convert it into a turbid, grayish-white liquid. If cultivated in 
a capsule containing 5 per cent, of nutrient gelatin, a few hours after inocula- 
tion, the most characteristic movements of the individual bacilli are observed 
on the surface of the gelatin, although at this early stage no liquefaction can 
be detected. The movements are not observed if the nutrient medium con- 
tains 10 per cent, of gelatin. Spore-formation was never observed. Injected 
subcutaneously in small doses, no results were obtained; larger doses some- 
times caused circumscribed abscess at the point of injection. Intravenous 
injection of a large dose produced toxic symptoms in rabbits and guinea-pigs, 
and these were not modified by using the filtrate of a liquefied culture, show- 
ing that the toxic substance was held in solution. 

Proteus Mirabilis. — Eods varying greatly in length, sometimes so short 
that they appear like cocci, at others of considerable length. 



368 



PRINCIPLES OF SURGERY. 



The rods occur singly and in zoogloea, and sometimes in tetrads, pairs, 
chains, or as short rods in twos, resembling bacterium termo; in fact, in all 
conceivable transition-forms. 

Cultivated on nutrient gelatin, they form a thick, whitish layer, in con- 
centric circles, which, in time, liquefies the medium. Similar movements are 
observed in capsule-cultivations as with proteus vulgaris. The pathogenic 
properties of the mirabilis are the same as those of vulgaris. 

Proteus Zenkeri. — Eods about four times as long as wide, in twos, like 
bacterium termo. Cultivated on nutrient gelatin, no liquefaction results, but 
a thick, whitish-gray layer is formed, with sloping margins. The bacilli are 
motile, and the same phenomena are observed on the solid medium as in the 
other forms. Spirilli and spiralinar forms are seldom seen. Gelatin and 
blood-serum cultures emit no fetid odor, but meat-infusion undergoes rapid 




Fig. 141.— Proteus Mirabilis. 285 : 1. Swarming Islets. (Hanser.) 

putrefaction and yields the usual fetid odor. The pathogenic qualities are 
the same as those of the other species of proteus. 

As the microbes of putrefaction, which have first been described, pos- 
sess limited op no pathogenic qualities when introduced into healthy tissue, 
it is evident that their toxic effect is caused by a soluble substance which they 
produce when they find their way into dead tissue exposed to atmospheric 
air. This leads us to a consideration of the 

Ptomaines. — Ptomaine is a term used to designate certain toxic sub- 
stances (resembling alkaloids) which are produced during the process of 
putrefaction. Gautier has shown that in dead animal tissues processes of 
putrefactive decomposition set in, by which certain alkaloids are elaborated 
from albuminous substances, which have been called ptomaines by Selmi. 



CLINICAL POEMS OF SEPTICEMIA. 369 

In the latter part of the seventeenth century Kircher and Leeuwenhoek 
claimed thai pntrid substances contained minute microscopical worms, which 
caused the putrefaction. In L820 Kerner pointed out the resemblance be- 
tween the symptoms of poisoning by sausages and by atropine. He was thus 
the first to raise the suspicion that toxic alkaloids were formed through the 
decomposition of albumen. In 1856 Panum showed that the inflammatory 
change which occurs in the intestinal mucous membrane of animals fed on 
putrid infusions is due to a chemical poison, which remained unaffected by 
boiling for a long time; and his conclusion that the toxic substance contained 
in putrid fluids was of a chemical nature was confirmed by Weber, Hemmer, 
Schweninger, Stich, and Thiersch. In 1875 B. W. Eichardson isolated a 
toxic substance, which he called "septine," from the inflammatory transuda- 
tion in the peritoneal cavity of a person that had died of pyaemia. With this 
substance he successfully infected animals. He also found that this sub- 
stance could be made to combine with acids, so as to form salts, without 
losing its toxic qualities. Bergmann and Schmiedeberg isolated a crystalline 




Fig. 142.— Involution Forms of Proteus Mirabilis. 524 : 1. (Hauser.) 

poison from decomposing yeast, to which they gave the name of "sepsin." 
This substance, when injected into the subcutaneous tissue or venous circula- 
tion in animals, produced well-marked symptoms of septic intoxication; the 
intensity of the symptoms were found to vary with the amount of the sub- 
stance injected. Zuelzer and Sonnenschein obtained, from macerated dead 
bodies and from putrid meat-infusions, small quantities of a crystallizable 
substance which exhibited the reactions of an alkaloid, and had a physio- 
logical action like atropine, dilating the pupil, paralyzing the muscular fibres 
of the intestine, and increasing the rapidity of the pulse. In 1857 Pasteur 
made the important discovery that specific microorganisms are the cause of 
the various forms of fermentation and putrefaction. ~No discovery, perhaps, 
attracted such universal attention as Pasteur's theory of fermentation. This 
theory was strengthened somewhat later by LemaireY observation, that all 
fermentative changes in fluids are suspended on the addition to the fluids of 
phenic acid, from which he concluded that fermentation must be due to 



370 PRINCIPLES OF SURGERY. 

living organisms. Next came the carefully-conducted experiments of Lister, 
who showed that air is deprived of its action in causing putrefaction of or- 
ganic substances if it is passed through a filter, or if the fluids are placed in 
an open vessel with the mouth of the vessel so arranged that dust cannot 
reach the fluid by gravitation. 

Lister's great life-work, antiseptic surgery, that has created a new epoch 
in the history of medicine and surgery, is based upon what then was still a 
theory, that inflammation, suppuration, and septic infection of wounds are 
caused by living specific microorganisms. Selmi discovered ptomaines in an 
exhumed body, in 1872. The ptomaines isolated by him were volatile alka- 
loids. Grautier, independently of Selmi, and about the same time, made the 
same observations, but believed that the toxic substances were volatile, and 
that in their action they resembled the narcotics, morphia and atropia, and 
were more nearly allied to the alkaloid extracted from poisonous mushrooms. 

Semmer gives an account of the action of septic substances as studied 
experimentally by Guttmann, of Dorpat. The experiments were made with 
putrid substances, products of inflammation, septic blood, and cultivations 
of septic bacteria. These researches showed that a chemical poison is formed 
in putrefying substances, and that a certain quantity of such poison produces 
symptoms of sepsis and death in animals. The blood of animals killed with 
such putrid poisons was found to possess no infective qualities, and the usual 
putrefactive bacteria were destroyed in the blood, and only appear again 
after the death of the animal. It was claimed, even at that time, that the 
bacteria elaborate the poison, as experiments made with cultures grown out- 
side the body produced the same effect. Another conclusion arrived at was 
that putrid substances administered subcutaneously may produce gangrene, 
phlegmonous inflammation, or erysipelas, according to the stage of putrefac- 
tion, temperature, culture-soil, etc. The infective material was never found 
in the blood, but always in the products of inflammation. It was clearly 
stated that true septicaemia is always preceded by a stage of incubation, and 
that its contagium is destroyed by boiling, putrefaction, and germicides. 

Bergmann and Angerer produced a condition in animals resembling 
septicaemia, by injecting into the circulation pepsin, pancreatin, and trypsin. 
When death occurred after intravascular injections of these ferments, fibri- 
nous deposits were found in the heart and pulmonary vessels. These experi- 
ments were, therefore, confirmatory of the observations previously made by 
Edelberg and Birck, who had shown that the injection of putrid substances 
into the circulation materially increased the free fibrin-ferment in the cir- 
culating blood. 

Blumberg concluded, from his numerous experiments on animals, that 
the symptoms which follow an injection of putrescent material into the cir- 
culation are not always constant; that, in fact, extreme prostration, high 



CLINICAL POEMS OF SEPTICEMIA. 371 

temperature, rapid pulse and respiration arc the only constant symptoms 
found. The same author also confirmed the statement that the blood of pa- 
tients dying from putrid intoxication contained no microorganisms. Sam- 
uel maintains that putrid fluids, from the second day until the eighth month 
of putrefaction, act differently, and divides their action according to this 
supposition into three stages: 1. Phlogog&nic, in which they produce only 
inflammation. 2. Septogenic, in which they produce in the living organism 
putrefactive processes. 3. Pyogenic, in which they cause only suppuration, 
having lost, in the meantime, their other pathogenic qualities. 

Mikulicz found that putrid fluids, according as they are free from bac- 
teria or contain more or less of putrefactive microbes, will produce a slight 
inflammation, a suppurative inflammation, or a progressive phlegmonous in- 
flammation. Frankel detected but few micrococci in the blood of septicemic 
patients, and observed that they greatly increased after death; but, after the 
lapse of some further time, altogether disappeared, thus also confirming a 
fact previously known, that putrefaction destroyed septic microbes. These 
observations may tend to harmonize the discrepancy of opinion, growing out 
of the different results obtained by different experimenters, by injections of 
putrid substances, as some of the fluids may have contained an abundance 
of living microorganisms, while others may have been rendered sterile by age, 
owing to advanced putrefactive changes. Brieger and Maas have rendered 
valuable service in the chemical isolation of ptomaines, or, as Brieger calls 
them, toxins, from putrid substances, and the results of their inoculation 
experiments established more firmly the fact of putrid intoxication by these 
soluble alkaloid substances. The number of bacteria in rabbits killed by 
septic infection is so great that death may ensue from simple mechanical 
causes, while in fatal cases of sepsis in man the number is often so small that 
it seems natural to suppose that the microorganisms are capable of producing 
some poisonous substance, which destroys the patient before they have time 
to multiply to the extent observed in septicaemia in rabbits and mice. 

Binne asserts that the chemical products of pus-microbes alone, as well 
as sterilized putrid fluids, never produce metastasis. He sterilized fluid 
cultures of the staphylococcus pyogenes aureus after filtration, and injected 
directly into the blood-vessels of rabbits as much as 4 grammes of this fluid, 
and in dogs increased the dose to 14 grammes. Many of the animals showed 
slight symptoms of septic intoxication, somnolence, diarrhoea, and collapse. 
By using still larger doses the symptoms were intesified and the animals died 
from well-marked symptoms of septic intoxication. Metastatic abscesses 
were never found in these cases. The same author has also published some 
very interesting observations on the immediate cause of death in rabbits 
inoculated with a pure culture of Koch-Gaffky's bacillus. The animals were 
inoculated at the base of the ear, and immediately after death the ptomaines 



372 PRINCIPLES OF SURGERY. 

were isolated from the tissues by Brieger's method. In every instance he 
obtained a substance called methylguanidin, which on chemical analysis was 
shown to consist of the formula C 2 H 7 N 3 . When this substance was injected 
into rabbits it produced symptoms of septic intoxication which resembled, 
in every particular, those produced by the injection of pure cultures obtained 
from septicemic rabbits. As methylguanidin could not be produced from 
the cadavers by the same method, Hoffa naturally came to the conclusion 
that it was a product of the bacilli, and that death was to be attributed to the 
production of this toxic substance in the tissues of the infected animals by 
the specific action of the bacilli. The source of methylguanidin in the body 
is creatin, and the bacteria must possess the property of oxidation, as creatin 
is transformed into methylguanidin only by oxidation. Brieger has isolated 
from human corpses a different set of toxic alkaloids, one of which he calls 
"cadaverin" and the other "putrescin," which are but feeble poisons; while 
two others, "madeline" and "sepsin," which are produced later on in the 
decomposition, are much more powerful poisons, causing paralysis and death. 
From decomposing albuminous substances he has obtained many other well- 
defined chemical bodies, as well as some substances to which no names have 
yet been given. 

Bourget isolated several toxic bases from the viscera of a woman who 
had died of puerperal sepsis. He also obtained from the urine of patients 
suffering from the same disease similar toxic bases, which killed frogs and 
guinea-pigs, when administered by injection, showing that the toxic sub- 
stances formed during life, and that they are eliminated through the kidneys. 

The experimental and clinical researches to which I have referred above 
show conclusively that septic intoxication is caused by the presence of dead 
tissue in the body in a state of putrefaction, from the presence of putrefactive 
bacilli, and that the immediate cause of the intoxication is the absorption -of 
preformed ptomaines from such a local focus of putrefaction. 

Symptoms and Diagnosis. — Septic intoxication sufficient in severity to 
give rise to grave general disturbances is usually initiated by a chill, or at 
least by a sensation of chilliness, followed by a continued form of fever, the 
temperature rapidly increasing to 102° to 104° P., with slight morning re- 
missions. The character of the pulse furnishes the most reliable information 
in regard to the intensity of the intoxication. All ptomaines of putrefactive 
bacteria exert a depressing influence on the heart; hence the force and fre- 
quency of the pulse furnish important diagnostic and prognostic evidences. 
The pulse is always soft and compressible: qualities which indicate dimin- 
ished intravascular pressure, resulting from an enfeebled vis a tergo. Com- 
plete loss of appetite, vomiting, and diarrhoea are almost constant symptoms 
in grave cases. The tongue is usually furred, dry, and, in severe cases, pre- 
sents the "dried-beef appearance. The urine is scanty and heavily loaded 



CLINICAI 1'okms or SEPTICEMIA. 373 

with urates. Eeadache is often complained of in the beginning of the at- 
tack. Delirium, restlessness, insomnia, are symptoms which denote ap- 
proaching danger. Subsultus, dilatation of pupils, clammy perspiration, 
livid appearance ot visible mucous membranes, low-muttering delirium, in- 
voluntary discharges, coldness o( the extremities, fluttering, and feeble pulse 
precede death from septic intoxication. One of the most important elements 
in the diagnosis is the detection of a local focus of putrefaction. As the 
putrefaction always occurs in parts of the body exposed to the atmospheric 
air. its existence can readily be ascertained by the sense of smell. The in- 
tensity of the fcetor of the gases produced by the putrefactive bacteria varies 
greatly, but the smell is always suggestive of decomposing meat or kitchen 
refuse. The impression is quite prevalent, not only among the laity, but also 
in the profession, that the local lesions which cause septicaemia always emit 
a fetid odor. This is a grave mistake. Fcetor is associated with 'putrefaction, 
and as such is suggestive of sapraemia, and not true progressive sepsis. The 
latter may be combined with sapraemia, but when it occurs independently 
of this no bad smell can be detected, and yet it is the most fatal form of sep- 
sis. In reference to the differential diagnosis between sapraemia, fermenta- 
tion fever, and septic infection, it must be rememberd that septic intoxica- 
tion can only occur from putrefaction, and therefore three conditions must 
invariably be present in the etiology of this form of sepsis: 1. Dead tissue. 
2. Infection of this dead tissue with putrefactive bacteria. 3. A sufficient 
length of time must have elapsed since the injury or operation for the putre- 
factive bacteria to produce a toxic quantity of ptomaines to cause symptoms 
of intoxication. The dead tissue may be a blood-clot in a wound, around the 
fragments of a compound fracture, or in the interior of the uterus; it may be 
tissue devitalized by a trauma, heat or cold, the action of chemical substances, 
or the action of bacteria other than putrefactive; or it may be detached, re- 
tained fragments of placental tissue. That such dead tissue has become the 
seat of infection with putrefactive bacteria can be ascertained by the presence 
of fcetor and bubbles of gas. At the temperature of the body putrefaction 
progresses very rapidly; but a differential diagnosis can generally be made 
without much difficulty, between sapraemia and fermentation fever, by the 
time which has elapsed between the injury or operation and the manifesta- 
tion of the first symptoms of septic intoxication. Fermentation fever ap- 
pears within a few hours, certainly always before the end of the first day, 
while septic intoxication from putrefaction seldom begins before the ex- 
piration of twenty-four hours. If septic infection begin during this time it 
is not attended by any evidences of putrefaction. 

Prognosis. — Uncomplicated sapraemia proves fatal by the absorption of 
a deadly dose of ptomaines from a local depot of putrefaction, and the prog- 
nosis will therefore depend upon the stage of intoxication and the feasibility 



374 PKINCIPLES OF SURGERY. 

of the removal of the infected dead tissue by surgical treatment. If an effi- 
cient, radical treatment can be instituted at a time before a fatal dose of 
toxic substances has reached the general circulation, the prognosis is favor- 
able. A decomposing blood-clot or detached fragment of a placenta can be 
readily removed and the field of operation sterilized. The prognosis in 
sapraamia complicating progressive gangrene is always grave, as the dead 
tissue is increased by other microbes; hence the conditions created by both 
kinds of microbes are of a progressive character. 

Treatment. — The prophylactic treatment of saprasmia consists in the 
removal of dead tissue, prevention of subsequent extravasation and accumu- 
lation of blood by careful hasmostasis, — if necessary, by drainage, — and 
finally sterilization, by antiseptic measures, of dead tissue that cannot be 
removed. Iodoformization of dead tissue is an excellent means of preserva- 
tion. In the extraperitoneal treatment of the stump after supravaginal ex- 
tirpation of the uterus, the same object is accomplished by touching the raw 
surface with a solution of perchloride or persulphate of iron or pure carbolic 
acid. Wounds in which dead tissue is unavoidably retained should always 
be treated by drainage. After symptoms of septic intoxication have devel- 
oped early, radical treatment must be pursued. This treatment comprises 
the removal or sterilization of the dead tissue. A decomposing blood-clot is 
to be removed and the parts are thoroughly irrigated with a solution of cor- 
rosive sublimate, and reaccumulation prevented by efficient drainage. In 
cases of gangrene complicated by putrid intoxication, where it is impossible 
to remove the infected tissues by mechanical measures, and complete disin- 
fection without such a procedure cannot be effected, the best results are 
obtained by permanent irrigation with a saturated solution of acetate of 
aluminum. Under this treatment the soluble toxic substances are washed 
away as fast as they are formed, and sterilization of the soil for the putre- 
factive bacteria is gradually accomplished by the saturation of the dead tis- 
sue with this safe and efficient antiseptic solution. If a suppurating cavity 
is the seat of putrefactive changes, it becomes necessary to remove the nu- 
trient medium for putrefactive bacteria by first washing out the cavity with 
a strong antiseptic solution, to be followed by the mechanical removal of 
dead tissue, shreds of connective tissue, dead granulations, etc., by means of 
a sharp spoon or dull curette, and subsequently by another antiseptic irri- 
gation. The surgical treatment of sapraamia will soon decide the fate of the 
patient. If a fatal dose of ptomaines has reached the general circulation 
before an effort is made to procure sterilization of a local depot of putrefac- 
tion, the local treatment will, of course, prove unsuccessful in preventing a 
fatal result, and the disease will continue its relentless course uninfluenced 
by the treatment. If, however, the intoxication has not progressed to this 
extent, efficient local treatment is followed by the most brilliant results. 



CLINICAL POEMS OF SEPTICEMIA. 375 

With in a few hours after the sterilization of the local focus of putrefaction 
the temperature falls to normal, the pulse becomes slower and fuller. If the 
tongue has been dry ii soon becomes moist; if the patient has been delirious 
consciousness returns, and the patient is convalescent in a few days. The 
results of the antiseptic local treatment in these cases are in strong contrast 
with the useless and often dangerous internal administration of antipyretics. 
The treatment directed toward the disinfection of the local focus of putre- 
faction removes the cause of the intoxication, while the antipyretics may 
effect a temporary reduction of the temperature, but at the same time, by 
diminishing the contractile power of the heart, only add to the danger by 
diminishing the resistance to the action of a depressing poison. The use of 
antipyretics in the treatment of saprgemia is strongly contraindicated. All 
debilitating treatment must be carefully avoided as being unscientific and 
as adding to the existing dangers. The best results are obtained by such 
local treatment by which the further production of ptomaines is prevented; 
consequently by measures which meet the etiological indications. The debili- 
tating effects of the ptomaines on the heart are met by the timely and judi- 
cious administration of stimulants. In urgent cases such diffusible stimu- 
lants as sulphuric ether, camphor, and musk can be administered with ad- 
vantage subcutaneously, in order to gain time for the action of remedies 
which will have a more permanent effect on the heart. Digitalis, strophan- 
tus, strychnia, and atropia in small doses are excellent cardiac tonics and 
stimulants, and are indicated in cases where the pulse is very rapid and soft, 
■denoting a feeble peripheral circulation from a weakened heart. Where life 
is threatened from syncope the patient is not allowed to assume a sitting 
position, for fear that the increased intracardiac pressure might result in 
sudden death from heart-failure. 

Alcoholic stimulants are to be given in doses sufficiently large to im- 
prove the character of the pulse, and at sufficiently short intervals to main- 
tain this effect without interruption. Brandy or whisky, in doses of an ounce 
every two hours, diluted with water, are most to be relied upon; but cham- 
pagne, Greek sherry, or Beich/s Tokayer are excellent substitutes. If the 
stomach is irritable or the symptoms are less urgent, concentrated liquid 
food, like beef-tea, milk, and eggnog, must be given at regular intervals to 
assist the action of stimulants in sustaining the heart's action until sufficient 
time has been gained for the elimination of the ptomaines. 

(c) Progressive Septicaemia. — This is the septic infection of modern 
authors, and differs from septic intoxication in that it is caused not by putre- 
factive bacteria, but by microbes which enter the circulation from some local 
septic focus, and which retain their capacity of reproduction in the blood. 
It is called progressive sepsis, because, only too often, it is not followed by 
any abatement of the symptoms, as the essential cause has passed beyond the 



3T6 PRINCIPLES OF SURGERY. 

reach of any local treatment, and goes on increasing in the "blood until it 
destroys the patient. The intoxication in this form of sepsis is not only caused 
by toxins which are produced at the primary seat of infection, but toxins are 
also produced in the blood by the microbes which it contains. 

True progressive sepsis is caused by the introduction of septic microor- 
ganisms into the tissues, where they multiply and, later, reach the blood, 
where mural implantation and capillary thrombosis take place, which di- 
rectly interfere with the proper nutrition and function of important organs, 
and where the septic intoxication is caused by the formation of toxins, both 
in the blood and living tissues. For this form of sepsis Xeelsen has suggested 
the name of '''acute mycosis of the blood," to distinguish it from putrid 
intoxication, which we have just described, and which Xeelsen calls ' 'toxic 
mycosis of the blood," in which few or no microbes are found in the blood, 
and in which death is due exclusively to the absorption of preformed toxic 
substances from a putrefying depot. 

Causes. — Klebs discovered and described a microbe, the micros poron 
septicum, which he believed was the specific cause of septic processes, but 
recent researches seem to prove that the pus-microbes are the most frequent 
cause of progressive sepsis. The pus-microbes either reach the circulation 
directly by permeating the vessel-wall, or they enter by a more indirect route, 
through the lymphatic channels. The latter mode of infection gives rise to 
the most acute and fatal form of sepsis. In many cases of septic infection 
the presence of lymphangitis can be demonstrated during life, and by exam- 
ination after death. A few years ago Bergmann advanced the theory that 
in septicaemia microorganisms enter the colorless blood-corpuscles, and by 
multiplication within them cause their dissolution, a process during which 
the fibrin-generators are elaborated: an occurrence ending in intravascular 
coagulation and capillary embolism. In Koch's septicaemia in mice such a 
chain of pathological conditions can be readily demonstrated: but in many 
cases of fatal sepsis in man the microbes found in the blood are few, no de- 
struction of leucoc}'tes can be shown to have occurred, and extravasations and 
capillary embolism are absent; hence death cannot be attributed to fibrin 
intoxication. In such instances ice can only assume the presence of a soluble 
toxin, which is diffused thro ugh out the entire body and destroys life by its toxic 
properties. The formation of pus at the primary seat of infection is not 
necessary in the causation of septicaemia by pus-microbes. Septic infection 
is as liable to take place from wounds that do not suppurate as from suppurat- 
ing wounds. Why a wound infected with pus-microbes should give rise to 
progressive sepsis in one individual, and suppuration or suppuration and 
pyaemia in another, does not admit of a satisfactory explanation at the pres- 
ent time. 

Einne has shown that diminution of the absorptive capacity of the tis- 



CLINICAL FORMS OF SEPTICEMIA. 3*3 3 

b a .; the seal of infectioD plays an important part in the development of 
Beptic processes. If the pus-microbes are rapidly absorbed, destroyed in the 

blood, or removed by elimination, septic inflammation is prevented. If, on 
the oilier hand, the local conditions are such that the microbes remain in the 
-. and by their rapid multiplication produce a large amount of soluble 
toxins, which, when they reach the blood, not only produce intoxication, but 
prepare the blood and tissues for the localization and reproduction of the 
microbes at points distant from the primary seat of the infection, the pathog- 
enic- effect of the microbes on the tissues at the primary seat of infection di- 
minishes their power of resistance, and the microbes either enter the blood- 
vessels directly or through the lymphatics. Experimentally it has been 
shown that if a large quantity of pus-microbes is introduced into the peri- 
toneal cavity, or directly into the circulation, death results from sepsis before 
a sufficient length of time has elapsed for the pus-microbes to produce the 
histological changes which are necessary for the production of pus. These 
experiments are strongly suggestive of the fact that, in man. infection with pus- 
microbes causes progressive sepsis, if a large quantity of pus-microbes is intro- 
duced into tissues debilitated by a trauma, antecedent pathological conditions, 
or the action of preformed- toxins. Under such circumstances the pus-mi- 
crobes are reproduced with great rapidity at the primary focus of infection, 
enter the circulation before suppuration has had time to develop, and pro- 
duce a complexus of symptoms and a series of pathological changes charac- 
teristic of progressive sepsis. 

Symptoms and Diagnosis. — The most typical clinical picture of progress- 
ive sepsis is produced in cases of septic peritonitis, dissection wounds, puer- 
peral septicaemia, and acute multiple osteomyelitis. In septic peritonitis, 
after laparotomy or penetrating wounds of the abdomen, the septic inflam- 
mation, as a rule, develops within the first forty-eight hours, and with it the 
characteristic symptoms of septicaemia appear. In puerperal sepsis and the 
gravest form of acute suppurative osteomyelitis, the septic symptoms often 
overshadow the primary disease to such an extent that this is entirely over- 
looked. Dissection wounds often prove fatal from septic infection, which 
spreads from the wound along the course of the lymphatic vessels, and finally 
becomes general through the medium of the circulation. Septic infection 
from an accidental or operative wound can take place within twenty-four 
hours, and seldom occurs later than the third or fourth day. unless the infec- 
tion has taken place after the first dressing. Like all other acute infectious 
processes, septicaemia is ushered in by a more or less pronounced chill, or at 
least a subjective sensation of chilliness, which may be repeated during the 
first twenty-four hours. The chill is never so pronounced as in pyaemia, and 
does not return with the same regularity and intensity as in that affection. 
The chill announces the termination of the period of incubation, and is 



o»8 PRINCIPLES OF SURGERY. 

promptly followed by symptoms of reaction which, in their severity, are pro- 
portionate to the intensity and gravity of the attack. One of the most promi- 
nent features of the disease is a profound prostration, which may be well 
marked a few hours after the beginning of the attack. If septicaemia follow 
an operation, or a severe accident, it is sometimes almost impossible to decide 
whether the pronounced loss of strength should be attributed to shock, haem- 
orrhage, the use of an anaesthetic, or the beginning of an attack of septicae- 
mia. One of the most delusive symptoms is the utter indifference of the 
patient, not only as to his own grave condition, but to all of his surround- 
ings. This apathy is a characteristic symptom of profound septic intoxica- 
tion. The patient complains of no pain, assures the physician and friends 
that he is feeling well, shows absolutely no anxiety concerning his own fate, 
and does not comprehend the anxiety of those around him. Drowsiness, 
bordering almost on stupor, is frequently observed. The face presents a pale 
or ashy-gray color, and in advanced cases it presents a yellowish, icteric tint, 
but the sclerotics always retain their white color. In the beginning of the 
attack the pulse ranges between 80 and 90, but becomes rapid, small, and 
compressible as the intoxication and capillary obstruction progress. The 
character of the pulse is of great diagnostic and prognostic importance. If 
the pulse within a short time reach a frequency of 140, and impart the sensa- 
tion as though the artery were only half-filled with blood, it is a symptom 
which forebodes immediate danger. The temperature is variable. A sub- 
normal temperature, with a rapid, feeble pulse, indicates a grave and prob- 
ably fatal form of sepsis. If the temperature is at first only slightly in- 
creased, but gradually rises to 103° or 104° F., it denotes progressive sepsis. 
A high temperature and a firm pulse, not exceeding 120 beats to the minute, 
are indications of less serious import than a low temperature with a rapid, 
feeble pulse. The eyes are sunken, often suffused with an abundant secre- 
tion from the conjunctiva. The features present a stolid appearance, with- 
out any expression of intelligence. Capillary oozing at the primary seat of 
infection is a common occurrence, and capillar}*- haemorrhage underneath the 
skin and visible mucous membranes is frequently observed. Vomiting and 
diarrhoea are often present from the beginning, and in rapidly-fatal cases 
remain as persistent symptoms, in spite of measures that may be employed to 
subdue them. The discharges from the bowels are often stained with blood. 
The urine, as a rule, is scanty and loaded with urates. 

Billroth placed great importance upon the appearance of the tongue. 
The tongue is always coated; in grave cases it is pointed at the tip, its mar- 
gins are red, while the dorsal surface is dry and covered with a dry, often 
almost black, crust. Eeturn of moisture is always a favorable omen. Great 
thirst and complete loss of appetite are always present. Delirium is a fre- 
quent, but not a constant, symptom. If the case progress to a fatal termina- 



CLINICAL FORMS OF SEPTICEMIA. 379 

tion, the pulse becomes more and more frequent, respirations become shallow 
and labored, the face presents a cyanotic hue, the surface is bathed with a 
clammy perspiration, the extremities become cold, and death finally is caused 
from heart-failure. In the differential diagnosis it is important to remem- 
ber fermentation fever, septic intoxication, typhoid fever, internal sepsis, and 
acute multiple suppurative osteomyelitis. Progressive septicaemia always has 
a stage of incubation; that is, a certain length of time intervenes between 
the time infection occurred and the appearance of the disease. This period 
of incubation may terminate at the end of a few hours and it may be pro- 
longed to four days, according to the number of pus-microbes introduced 
and the anatomical structure and. physiological properties of the tissues pri- 
marily infected. Fermentation fever follows an injury or operation within 
a few hours, and never occurs after the expiration of twenty-four hours. In 
fermentation fever the maximum symptoms appear at once, and the force of 
the pulse and strength of the patient remain unimpaired. Fermentation 
fever seldom lasts for more than one or two days, while in progressive sepsis 
the symptoms become aggravated as the infection increases. In putrid in- 
toxication the maximum symptoms are produced by the introduction into 
the blood of preformed soluble toxic substances from a depot of putrefaction. 
Evidences of putrefaction in any part of the body would speak in favor of 
septic intoxication, while, if septic infection exist at the same time, it must 
be regarded not in the light of a cause, but as a complication. Typhoid fever 
is preceded by a well-marked prodromal stage which is absent in septic in- 
fection. The eruption in typhoid fever is characteristic, while the eruption 
which is sometimes seen in progressive sepsis closely resembles the rash of 
scarlatina, and is caused by the presence of pus-microbes in the superficial 
lymphatic vessels. Internal sepsis is usually preceded by a septic pharyn- 
gitis, and frequently attended by ulcerative endocarditis. Acute multiple 
osteomyelitis, the cause of fatal septic infection, can be recognized by search- 
ing for points of tenderness in the localities attacked most frequently by this 
disease. The final diagnosis of septic infection must be based upon the ex- 
istence of an infection-atrium, through which pus-microbes have entered the 
tissues, and from which they have reached the general circulation. 

Prognosis. — The prognosis of progressive septicaemia is always grave. 
In cases where pus-microbes exist in large numbers at the primary seat of 
infection, and reach the general circulation with great rapidity, and meet 
with conditions favorable for their reproduction, death is inevitable in spite 
of the most energetic local and general treatment. The prognosis is more 
favorable if infection has taken place from a locality amenable to thorough 
local disinfection, if this is practiced upon the first appearance of symptoms, 
as this treatment prevents further ingress of pus-microbes into the circula- 
tion. The existence of multiple points of metastatic inflammation renders a 



380 PEINCIPLES OF SUKGEEY. 

recovery improbable. Delirium, rapid and feeble pulse, subnormal tempera- 
ture, dry tongue, persistent vomiting and diarrhoea are all unfavorable symp- 
toms from a prognostic stand-point. Capillary haemorrhages distant from 
the primary infection-atrium are infallible indications of progressive sepsis, 
and their existence warrants a most unfavorable prognosis. Progressive sep- 
sis may cause death in twelve hours, and in fatal cases life is seldom pro- 
longed for more than one week. 

Pathology and Morbid Anatomy. — In rapidly-fatal cases of progressive 
septic infection, the absence of gross macroscopical pathological changes is a 
characteristic feature of this disease. In such instances even the most careful 
search for tangible lesions will result negatively. Cloudy swelling of the 
parenchyma of internal organs indicates the existence of coagulation-necro- 
sis, caused by the action of the toxins of the pus-microbes. Pus-microbes 
have been frequently found in septic blood. Hemorrhagic extravasations 
into organs, and more particularly underneath serous and mucous mem- 
branes and the skin, are frequently present. The blood presents almost a 
black color, and shows little or no tendency to coagulate. The lymphatics 
interposed between the primary seat of infection and the blood-vessels are 
frequently found in a state of septic inflammation. The wound through 
which infection has taken place may present but slight or no gross anatom- 
ical changes. The spleen is enlarged and the pulpa softened to the consist- 
ency of a blood-clot. Thrombosis and embolism are absent. Under the 
microscope the capillary vessels everywhere present all the evidences of a 
septic inflammation. The soluble toxins in the blood produce coagulation- 
necrosis of the intima, which determines mural implantation of the pus- 
microbes and the colorless corpuscles and results in capillary hyperemia and 
congestion. In some places alteration of the capillary wall has taken place 
to such an extent as to give rise to rhexis. The most important microscopical 
changes in the tissues and organs, in patients who have died of sepsis, are the 
pathological conditions within and in the immediate vicinity of capillary 
vessels that indicate the existence of multiple foci of metastatic inflamma- 
tion, which characterize clinically and pathologically progressive sepsis. If 
life is prolonged for a sufficient length of time, these foci become the centre 
of a suppurative inflammation. Slight effusions into the large serous cavities 
are frequently found. 

Treatment. — The antiseptic measures which have been described in the 
treatment of wounds are the best and only known means of effective prophy- 
laxis against septic infection. Any method or methods of treatment which 
can be relied upon in the prevention of suppuration will be found efficient 
in preventing septic infection. As retention of wound-secretion is one of the 
important etiological conditions in the causation of septic infection in 
wounds that are not completely aseptic, drainage should be employed in all 



( i.!\ [C Al. I'OKMs OF SEPTIOffiM] L. 381 

- where an accumulation of the primary wound-secretion is to be feared. 
As Beptic infection is just as liable to occur through a small as a Large wound, 
the most insignificant injury should be treated upon the strictest and most 
pedantic antiseptic precautions. If, in spite of the greatest care, symptoms 
of septic infection appear after an injury or operation, no time should be 
lost by the useless administration of antipyretics, in the vain hope that by 
reducing the temperature the condition of the patient will be improved, but 
the first and essential object of treatment should be to remove the cause of the 
fever by resorting to secondary disinfection. All sutures must be removed 
and every portion of the wound rendered accessible to local treatment. Ex- 
tra vasated blood and necrosed shreds of tissue must be removed, when the 
wound is to be irrigated with a l-to-1000 solution of corrosive sublimate or 
a 5-per-cent. solution of carbolic acid, after which it is dried and the whole 
surface brushed with a 10-per-cent. solution of chloride of zinc. After an- 
other irrigation and after drying the surface again, a thin film of iodoform is 
applied, and then the wound is tamponed with iodoform gauze, over which 
a moist antiseptic compress is applied. Such a wound should never be re- 
sutured until the local and general symptoms indicate that it has been ren- 
dered completly' aseptic. If this secondary disinfection prove unsuccessful, 
recourse should be had to permanent irrigation with a saturated solution of 
acetate of aluminum. Secondary disinfection of the peritoneal cavity, in 
cases of septic peritonitis after laparotomy, has so far not proved very satis- 
factory, but as it is the only recourse in dealing with such desperate cases, 
that, without it, would surely run a fatal course in a short time, it should 
never be neglected. A number of the sutures near the lower angle of the 
wound are removed, with blunt instruments the margins of the wound are 
separated, and the abdominal cavity is flushed with warm salicylated water 
until the fluid returns perfectly clear. The end of the rubber tube attached 
to the irrigator must be inserted in such a manner that the stream will reach 
the most dependent portions of the abdominal cavity; hence it is inserted 
into the deepest portion of the pelvis, and when this portion of the abdom- 
inal cavity has been thoroughly washed out the lumbar regions are dealt with 
in a similar manner. After the irrigation has been completed, the patient 
is turned upon the face, so as to permit the escape of fluid by gravitation. 
A large glass drain is lightly packed with a strip of iodoform gauze, after 
which the antiseptic dressing is applied in such a manner that the end of the 
tube remains accessible to the removal of fluid by aspiration as often as cir- 
cumstances may require. In progressive sepsis, following in the course of 
progressive gangrene of a limb, amputation will become necessary if second- 
ary disinfection and permanent irrigation have proved of no avail in arrest- 
ing the septic infection. The general treatment of septic infection is the 
same as has been advised in cases of septic intoxication. 



382 PEINCIPLES OF SUKGEKY. 

The general treatment of sepsis consists in the employment of stimu- 
lants, notably alcohol and strychnia, not in measured doses, but in quantities 
which will produce the desired result. 

INTESTINAL SEPSIS. 

The subject of intestinal sepsis, in connection with the bacillus coli 
communis, has received a good deal of attention, during the last five or six 
years, on the part of bacteriologists, physicians, and surgeons. Intestinal 
infection may be limited to the absorption of the toxins of pathogenic bac- 
teria., when it is called intestinal toxaemia, enterosepsis (Billroth), enteritis 
septica (Gussenbauer), or it may be of a more dangerous character when the 
bacteria enter the general circulation from the intestinal mucous surface. 
Karlinski fed animals with milk infected with staphylococcus aureus. 
Among forty-eight experiments he found six times general infection with 
swelling and redness of the intestinal mucosa, while the fasces and the blood 
both showed the same cocci. Five times he found suppurative parotitis with- 
out intestinal lesions; seventeen times, acute and fatal diarrhoea; eight 
times, general infection with metastatic abscess. Aside from these experi- 
ments, there are numerous other observations, all tending to show that the 
most common microbe of the intestinal canal, the bacillus coli communis, 
may enter the general circulation and, becoming localized in distant parts, 
cause suppuration. In this way are to be explained the abscesses in the liver 
which accompany or follow dysentery, and in which living microbes have 
been described by Kartulis, Osier, and others. Constipation is not an essen- 
tial condition in the production of intestinal toxaemia and sepsis, as, in some 
cases, for reasons which at present cannot be explained, these conditions are 
associated with diarrhoea. 



CHAPTER XV. 



PYiEMIA. 



Pyemia, or pyohsemia, is a general disease caused by the entrance into 
the circulation of pus or some of its component parts, characterized by re- 
curring chills, an intermittent form of fever, and the occurrence of meta- 
static abscesses. Although this disease was known a long time before Piorry 
applied to it the name it still bears, its intimate relationship to suppurative 
processes was first pointed out by this surgeon. Piorry maintained that, as 
the name implies, pyaemia is caused by the entrance of pus into the blood. 
Virchow, on the other hand, contended that no pus is found in the blood 
of pyaemic patients, and that the secondary or metastatic abscesses are not 
true abscesses resulting from the accumulation of pus derived from the 
blood, but that they are the result of embolic processes, puriform softening, 
inflammation, and suppuration around the blocked vessels. Recent bacterio- 
logical investigations have shown that Piorry' s views are so far correct in 
that pus is produced within blood-vessels by the entrance of pus-microbes 
into the circulation. As a wound complication pyaemia can only occur after 
suppuration has taken place in a wound, and, as a complication of non-trau- 
matic lesions, it can only develop in the course of suppurative affections. 
The great prevalence of pyaemia in overcrowded and badly-ventilated hos- 
pitals, during the time before the antiseptic treatment of wounds came into 
use, gave rise to a general belief that the disease was due to a specific cause, 
and ever since bacteriology became a science diligent search has been made 
to discover the specific microbe. Since the discovery of the microbes of sup- 
puration, new light has been shed upon the etiology and pathology of this 
disease. Bacteriological examinations of pyaemic products have shown that 
one or more kinds of pus-microbes are always present, thus establishing the 
direct relationship which exists between a suppurating process in some part 
of the body and the development of metastatic or pyaemic abscesses. Clinical 
experience has only corroborated the scientific investigations of this subject, 
inasmuch as it has shown that the frequency of pyaemia has been diminished 
in proportion to the lesser frequency of suppurative inflammation under the 
antiseptic treatment of wounds and suppurating lesions. We are justified, 
upon the basis of well-established facts, in claiming that pyaemia is not a 
disease per se, but that its occurrence depends upon an extension of a sup- 
purative process from the primary seat of infection, and suppuration in dis- 
tant organs by the transportation of emboli infected with pus-microbes 
through the systemic circulation. The distant, or metastatic, abscesses con- 

(383) 



384 PRINCIPLES OF SURGERY. 

tain the same microbes which are found in the wound-secretions, or in the 
abscess from which the general purulent infection took place. Experiments 
have shown that a culture of pus-microbes from a furuncle may produce 
pyaemia in animals, and that the microbes cultivated from a pyaemic abscess, 
when injected under the skin of an animal, may cause only a localized sup- 
purative inflammation without any general symptoms. 

BACTERIOLOGICAL AXD EXPERIMENTAL RESEARCHES. 

"While the direct relationship existing between suppuration and pyaemia 
was well understood clinically for a long time, it was left for Klebs to dem- 
onstrate for the first time the direct connection of the pyaeniic processes with 
the presence of specific microbes. In his researches into the nature of this 
disease during the Franco-Prussian war in 1870, he discovered in the pyaemic 
products certain microorganisms which he called micrococci of pyaemia. He 
found that these microbes always arranged themselves in the form of colonies 
or groups which he termed zobglcea. He found this microbe invariably pres- 
ent, notably at the primary seat of infection, but also in the most distant 
organs, — wherever, indeed, pathological changes occurred during the course 
of the disease. Pasteur, in studying the puerperal form of pyaemia, discov- 
ered a chain coccus which undoubtedly was identical with the streptococcus 
pyogenes, but which he called microbe en chapelet. Hueter and Vogt found a 
microorganism in pyaemic products which they included among the monads. 
Burdon-Sanderson supposed that he had discovered the essential microbic 
cause of pyaemia in the shape of a "dumb-bell-sha ped germ" which in all prob- 
ability was a staprrylococcus. 

Schuller examined the contents of metastatic joint affections in 12 cases 
of puerperal pyaemia, and invariably found pus-microbes. Rosenbach in- 
vestigated 6 cases of typical pyaemia with a view to determine the nature of 
the microbes present in the pyaemic products. He found the streptococcus 
pyogenes present in the blood, and metastatic deposits in 5 of them; in 2 of 
these cases staphylococci were also present, although fewer in number. In 
only 1 of them he found staphylococci alone, and this case recovered. Paw- 
lowsky made a bacteriological examination of the pus of metastatic abscesses 
in 5 cases of pyaemia. In -± cases he found the staphylococcus pyogenes 
aureus, and in the fifth case, which was remarkable for the extent of the 
joint complications, he found the streptococcus pyogenes. He believes that 
the staphylococcus pyogenes aureus is the usual cause of pyaemia, and espe- 
cially of that form characterized by multiple abscesses in the internal organs. 
Large cultures of this coccus suspended in water and injected subcutaneously 
in rabbits caused death, and at the necropsy multiple abscesses were found. 
He maintains that pyaemia in man occurs when disturbances in the circula- 
tion are present, so that floating cocci find favorable points for localization 



BACTERIOLOGICAL AND EXPERIMENTAL RESEARCHES. 385 

within the blood-vessels. Ee created such disturbances artificially in ani- 
mals by making intravenous injections of cinnabar, with the result that the 
granular material determined localization of the microbes which were intro- 
duced into the circulation. 

Besser examined bacteriologically blood, pus, and parenchymatous fluid 
from organs in 23 cases of pyaemia. In 8 cases the staphylococci albi and 
aurei were found; in 14, streptococci; and in 1, streptococci and staphylo- 
cocci simultaneously. The microbes were discovered during the patient's 
life in pus in every one of 20 cases examined; in blood, in 11 of 12; and in 
parenchymatous serum, in 1. After death, in pus, in 17 of 17; in blood, 4 
of 9; and in organs, 9 of 14. Besser s predecessors described 23 additional 
cases of pyaemia, in 14 of which staphylococci were found; in 7, streptococci. 
Total, 46 cases: in 22, staphylococci; in 21, streptococci; in 3, both. Besser 
was unable to detect the slightest morphological or pathogenic difference 
between the microbes of suppuration and those of pyaemia. 

Okinschitz made the relationship which exists between the pus-microbes 
and pyaemia the subject of bacteriological investigation. He found that 
pyaemic blood invariably contained either the streptococcus pyogenes or the 
staphylococcus pyogenes aureus, demonstrated by cultivation and ordinary 
microscopical examination. As the haemic microbes seldom show any signs 
of fission, as compared with the bacteria at the primary focus, it is reason- 
able to infer that reproduction takes place mainly in the pus, and not in the 
blood; hence the great importance of thorough disinfection and destruction 
of primary foci. The number of microbes in the circulating blood bears a 
direct relation to the gravity of the disease. If they are abundant, even in 
the absence of metastases in internal organs, the prognosis is grave, and if 
scanty, even if metastatic foci are present, the prospects of a favorable ter- 
mination are better. 

Masius and Beco record two cases of pyaemia due to the staphylococcus, 
in both of which they discovered the microorganisms in the blood. Kose 
injected animals with virulent cultures of the staphylococcus after injection 
of attenuated cultures. The animals survived. The blood caused a marked 
agglutination of staphylococci, and these organisms would not grow on thin 
blood-serum. He believes that this behavior of microbes is a matter of great 
importance, as it may indicate that we have in Widal's method a means of 
making an accurate diagnosis of the nature of infections in endocarditis and 
septicaemia. He also suggests that an antistaphylococcic serum may prove 
more efficient as a therapeutic agent than the antistreptococcic serum, since 
staphylococci are not so variable in virulence as the streptococci. 

Pyaemia in Rabbits. — Koch produced pyaemia artificially in rabbits by 
injecting putrid fluids. A piece of a mouse's skin, about a square centimetre 
in size, was macerated for two days in 30 grammes of distilled water, and a 



386 



PRINCIPLES OF SURGERY. 



syringeful of this fluid was injected subcutaneously into the back of a rabbit. 
Two days the animal remained apparently well, then it began to eat less, 
became gradually weaker, and died one hundred and five hours after the in- 
jection. An extensive subcutaneous abscess was found at the seat of injec- 
tion. In the abdominal wall the yellowish infiltration extended in part 
through- the muscles and even to the peritoneum. The peritoneal surface 
presented evidences of inflammation. The intestines were adherent, and the 
peritoneal cavity contained a small quantity of turbid fluid. The liver 
showed, on section, gray, wedge-shaped patches. In the lungs infarcts the 



r^ 



M 



: 



^-•D 



Fig. 143. — Vessel from the Cortex of the Kidney of a Pysemic Rabbit. A, nuclei 
of the vascular wall; B, small group of micrococci between blood-corpuscles; G, dense 
masses of micrococci adherent to the wall and inclosing blood-corpuscles; D, pairs of 
micrococci at the -border of the large mass. X 700. (Koch.) 1 



size of a pea were found. A syringeful of blood taken from the heart of this 
animal was now injected under the skin of the back of a second rabbit. The 
second animal died in forty hours, and at the necropsy nearly the same 
pathological conditions were found, only that the peritonitis was less ad- 
vanced. Further experiments showed that 1 / 10 drop of pysemic blood proved 
fatal in rabbits in one hundred and twenty-five hours. All subsequent ex- 



1 Copied from 
Society, London. 



'Traumatic Infective Diseases," by permission of the New Sydenham 



BACTEEIOLOGICAL AM> BXPEBIMENTAL RESEABCHES. 387 

periments proved that, the Less the quantity of blood injected, the longer the 
time which elapsed before death occurred; but where the quantity was re- 
duced ro the one-thousandth part of a drop, no result followed. On micro- 
scopical examination cocci wore found in great numbers everywhere through- 
out the body, and more especially in the parts which had undergone altera- 
tions visible to the naked eye. 

The description of the microbe found corresponds with the staphylo- 
coccus. The relation of the microbes to the blood-vessels could be seen best 
in the renal capillaries (Fig. 143). In the interior of the vessel, at 0, is a 
dense deposit of micrococci adherent to the wall, and inclosing in its sub- 
stance a number of red blood-corpuscles. The capillary stasis is either due 
to the power of the microbes of causing the red blood-corpuscles, to which 
they adhere, to stick together, or their property of producing in their imme- 
diate vicinity coagulation of the blood, and thus cause thrombosis. The mi- 
crobes were found so arranged that they inclosed red blood-corpuscles in the 
capillary vessels of all the organs examined, as, for example, in the spleen 
and in the lungs. Koch believes that the large metastatic deposits in the 
liver and in the lungs do not arise by gradual growth of a mass of micro- 
cocci, as in Fig. 143, but by the arrest of large groups and of the clots asso- 
ciated with them; in other words, by true embolism. In the metastatic de- 
posits an extensive development of micrococci occurs, and these are not con- 
fined to the vessels, but invade the neighboring tissues. In the peritoneal 
cavity the micrococci were not found in large masses, but isolated, in pairs or 
in small groups. 

In the vicinity of the abscess he detected the microbes in the walls of 
veins, and their passage through these into the interior of the vessels could 
be readily discerned in many places. As Koch has pointed out, the microbe 
of pyaemia in rabbits, which is a pus-microbe^ when brought in contact with 
the red blood-corpuscles, increases their viscosity and they form larger or 
small coagula in the blood. They can thus no longer pass through the 
minute capillary net-work, but are arrested in the smaller vessels. From the 
point of infection fresh micrococci pass constantly into the blood, and also 
individual micrococci will become detached from these small thrombi and 
emboli, and mix with the blood-stream. As the microbes are constantly be- 
ing deposited by mural implantation, their number in the circulating blood 
always remains relatively small. Klein described a micrococcus of pyaemia 
in mice. Certain cocci which were present in pork proved fatal to mice in 
about a week, producing both purulent inflammation at the point of injec- 
tion and metastatic abscesses in the lungs. Inoculations in the same species 
of animal with pyaemic products reproduced the disease in a typical manner. 
Pawlowsky found that by simultaneous injection of sterilized cinnabar, and 
of cultures of staphylococcus pyogenes aureus into the circulation, he pro- 



388 PRINCIPLES OF SUEGEEY. 

duced abscesses in various organs; in fact, the typical picture of pyaemia. 
The presence of particles of foreign bodies rendered material aid in the de- 
velopment of metastatic abscesses, as the mere arrest of pus-microbes in the 
circulation without them, as a rule, was not found sufficient of itself to lead 
to the production of true pyaemia. In rabbits, even, the introduction of a 
large quantity of a culture of pus-microbes into the circulation did not pro- 
duce pyaemia. Twenty-four hours after the injection he found the microbes 
in large numbers in the pulmonary and other capillaries, but after forty- 
eight hours they had all disappeared from the blood. If the cocci are in- 
corporated in, or are attached to, an embolus, this latter, by producing altera- 
tions in the endothelia of the blood-vessels at the point of impaction, creates 
a locus mmoris resistentice favorable to the growth of the microbes. In the 
experiments of Pawlowsky, the particles of cinnabar acted upon the endo- 
thelial lining of the capillary vessels in the same manner as the fragments of 
a thrombus, by impairing the local nutrition of the tissues with which they 
were brought into contact. 

ETIOLOGY. 

If pyaemia can be artificially produced in rabbits, mice, and guinea-pigs 
with pus or with a pure cultivation of the same with or without the presence 
of foreign bodies, the same local conditions are first produced at the point 
of inoculation which invariably precede the development of pyaemia in man. 
Some of the veins at the seat of primary infection are invaded by pus-mi- 
crobes, and become blocked by a thrombus; this thrombus undergoes puri- 
form softening; small fragments containing pus-microbes become detached 
and are washed away and enter the general circulation as emboli, which, 
when they become arrested, establish independent centres of suppuration. 
In such cases the same microbes can be found in the wound, in the blood, 
in the tissues around the abscess, and in all distant pyaemic products. Al- 
though the streptococcus pyogenes has been found most frequently in the 
pus at the primary seat of infection and in the metastatic abscesses of p} T - 
aemic patients, there can be but little doubt that any of the pus-microbes, 
when present in sufficient quantity in the blood, can produce the disease. 
The occurrence of pyaemia from suppurating wounds or abscesses does not 
depend so much upon the kind of pus-microbes which have caused the primary 
suppuration as upon surrounding circumstances. The location and ana- 
tomical structure of the tissues in which the primary infection has taken place 
exert an important influence in the production of the disease. 

It is an exceedingly familiar clinical fact that suppurative inflammation 
of the medullary tissue in bone is frequently the cause of pyaemia. Acute 
suppurative osteomyelitis without direct infection through a wound is always 
due to intravascular infection: localization of pus-microbes in the capillary 



ETIOLOGY 



389 



the medullary tissue. The microhes come first in contact with the 
endotheUal-cells when mural implantation lias taken place, and the coagula- 
tion-necrosis which follows leads to thrombosis. The products of the intra- 
vascular coagulation-necrosis furnish a most favorable nutrient substance for 
growth and multiplication of the pus-microbes; consequently the area 
of intravascular infection is rapidly increased. The growth of the throm- 
bus in a proximal direction soon leads to extensive thrombophlebitis, and, 
tening of the thrombus takes place, to embolism and metastatic sup- 
puration. Pyaemia following a suppurative inflammation in a wound, or in 
the course of a phlegmonous inflammation of the connective tissue, is the 
result of an infection with pus-microbes which penetrate the veins from 
without. The pus-microbes, coming first in contact with the outer coats of 
the veins, give rise to phlebitis, which progresses from without inward, and 
which is followed by thrombosis as soon as the intima is reached. The intra- 




Fig. 144.— Suppurating Thrombus in Vein. (Tilhnaniis.) 

vascular dissemination of the pus-microbes then takes place in the same 
manner as in cases of primary thrombophlebitis. Ordinary pyogenic microbes 
may and do cause pycemia, if they enter the Mood incorporated in, or attached 
to, fragments of an infected blood-clot, or other solid materials, which, after 
they have become impacted in blood-vessels as emboli, prepare the soil in distant 
organs for their localization and reproduction. 

The importance of thrombosis and embolism as essential factors in the 
causation of pyaemia has been clearly established by clinical observation and 
experimental research. Emboli may originate in the lymphatic vessels when 
these are the seat of invasion by pyogenic microbes, which, however, is very 
seldom the case. In chronic pyaemia, in which multiple metastatic abscesses 
are formed, embolism takes no essential part in the process; the microbes 
enter the blood-current without such a vehicle, and are brought in direct 
contact by mural implantation with the interior lining of vessels weakened 
by injury or other local and general debilitating influences. Experimental 



390 PRINCIPLES OF STJBGEBY. 

research has shown conclusively that the mere introduction of pus-microbes 
into the circulation is not necessarily, or even usually, followed by pyaemia, 
and their accidental entrance in the course of a suppurative inflammation is 
not always followed by serious consequences. There can be no doubt that 
some pus-microbes reach the circulation in nearly every case of suppuration, 
but their pathogenic action is prevented, or neutralized, by an adequate resist- 
ance on the part of the tissues with which they are brought in contact and 
their rapid elimination through healthy excretory organs. A limited number 
of pus-microbes injected into the circulation of a healthy animal, or acci- 
dentally introduced into the blood of an otherwise healthy person, are effect- 
ively disposed of by the white blood-corpuscles. If, however, the same num- 
ber of microbes are present in combination with fragments of a blood-clot, 
the infected foreign particles produce such nutritive changes in the tissues 
surrounding them as to transform them into a favorable soil for the pathog- 
enic action of the microbes. The same happens if free pus-microbes localize 
in a part the vitality of which has been previously diminished by trauma or 
antecedent pathological changes, which constitutes a locus minoris resistenti<:e 
for the growth and multiplication of the pus-microbes. Pyaemia, therefore, 
must be looked upon rather as a serious and fatal complication of suppura- 
tive lesions than an independent specific disease. The immediate causes of 
pyaemia are the formation of an infected thrombus at the primary seat of 
infection, and disintegration of this thrombus to such an extent that frag- 
ments become detached and are conveyed by the blood-current to distant 
organs, where they are arrested in the smaller arteries as emboli. 

Thrombosis. — A thrombus is an intravascular blood-clot locally formed 
within the heart or a blood-vessel, and the process by which it is formed is 
called "thrombosis." A thrombus is called venous if it occur in a vein, arte- 
rial if it form in an artery. A reel thrombus is produced if the blood coagu- 
late in its entirety, while a white thrombus is composed of fibrin exclusively 
or the fibrin and the colorless and third corpuscles of the blood. A mural 
thrombus is a thrombus which is attached to the inner surface of a vessel- 
wall without occluding the entire lumen of the vessel. Xotwithstanding the 
numerous and ingenious experiments which have been made for the purpose 
of ascertaining the immediate cause of intravascular coagulation of the 
blood, this subject awaits a more satisfactory explanation than can be given 
at the present time. Eichardson, Bruecke, and Lister have shown that the 
mere mechanical interruption to the flow of blood in a vessel is not a suffi- 
cient cause of coagulation. Blood has been kept in a fluid condition in a 
blood-vessel between two ligatures for an indefinite period of time in the 
living tissues. 

Virchow, Cohnheim, Baumgarten, and Zahn maintain that the colorless 
corpuscles are in the closest manner related to thrombus-formation. Zahn, 



ETIOLOGY. 391 

from observations on the Living mesentery of the frog, found thai when the 
wall o\ a vessel was injured the colorless corpuscles accumulate around the 
injured part, constituting what he rails a white thrombus. The corpuscles 
subsequently, in greal part, disintegrate and give rise to a granular accu- 
mulation, which, by its action upon the fibrinogen of the blood, causes a 
precipitation of fibrin. 

Siiuo the discovery of the third corpuscle, or liwmatoUast, by Hayem 
and Bizzozero, the part taken by this element of the blood in the process of 
coagulation has been carefully studied by Eberth and Schimmelbusch. The 
third corpuscle possesses a peculiar property to adhere to any foreign body or 
irregularity of surface of the intima of the blood-vessels. The authors just 
quoted found that when a vessel is injured, as by tying a ligature around it 
and removing this in a quarter of an hour afterward, these minute blood- 
disks manifest a peculiar tendency to adhere to the injured part of the tunica 
intima and to each other, forming a white mural thrombus. The process by 
which mural implantation of the third corpuscle takes place these authors 
call conglutination, the mass thus formed being composed primarily and ex- 
clusively of this morphological element of the blood. If an aseptic thread is 
drawn across the lumen of a vessel in which the blood-current is moving, 
the third corpuscle is arrested in its course and becomes deposited upon the 
thread, which, in time, becomes the centre of a white thrombus. Conglu- 
tination, under such circumstances, is a purely mechanical process. 

Eberth and Schimmelbusch demonstrated by their experiments that 
conglutination is most liable to occur where irregularities of the tunica 
intima are present. If by a trauma, inflammatory or degenerative changes 
take place, the endothelial lining of a blood-vessel is rendered rough and un- 
even; conglutination takes place first at the points which project farthest 
into the lumen of the vessel, because here the projecting body encroaches 
upon the axial current, which conveys the third corpuscle. In thrombosis 
through pathological causes, mural implantation of the third corpuscle takes 
place upon an intima roughened by inflammatory or degenerative changes. 
Arnold has very recently shown that the red corpuscles take an important 
part in the coagulation of blood both inside and outside of the body. His 
studies of the morphology of disintegration-product of red blood-corpuscles, 
both outside of the body as well as within the vessels of the mesentery and 
omentum of living animals, establish the very probable identity with blood- 
platelets of some of the bodies which separate from the red corpuscles by 
processes which are designated as plasmoschisis, or erythrocytoschisis, and 
plasmorrhexis, or erythrocytorrhexis. In addition, substances in solution 
may escape from the red corpuscles, which are then changed into "shadows" 
and other forms, or disappear entirely. This is called plasmolysis. In both 
of these changes — the extrusion of solid particles and plasmolysis — fibrin, 



392 PRINCIPLES OF SURGERY. 

different structurally as well as tinctorially, is formed, smooth threads, 
threads partly or wholly granular, threads containing platelets, and frag- 
ments of red corpuscles, showing that a very close relation exists between 
fibrin-formation and the red corpuscles. 

The investigations of Arnold furnish strong evidence in favor of regard- 
ing the formation of platelets as the first morphological phase of coagulation, 
not only in circulating blood, as suggested by Welch, but also in extravas- 
cular coagulation. The production by the red corpuscles of soluble fibrinoid 
substances may induce the deposition of fibrin around leucocytes and endo- 
thelial cells in such a manner as to reproduce the craters of coagulation 
described by Zenker and Hauser, in which the cells mentioned form the cen- 




Fig. 145. — White Thrombus, o, slightly granular and hyaline masses produced by the 
third corpuscle; b, white corpuscles; d, young blood-vessel. (Landerer.) 

tres, radially fibrinous threads. Thrombus- formation, as we observe it in 
pycemia, always takes place upon a vessel-wall altered by action of pus-mi- 
crobes. The form of thrombosis intimately associated with the etiology and 
pathological anatomy of pyaemia occurs in a vein within or in close proxi- 
mity to the primary suppurative lesion. The close relationship of phlebitis 
to pyaemia was well understood by John Hunter, who believed that the for- 
mer always preceded the latter. He taught that the phlebitis resulted in 
intravenous production of pus and the formation of metastatic abscesses. 
Cruveilhier, on the other hand, regarded thrombosis as the first link in the 
chain of pathological conditions in pyaemia. The idea of a primary throm- 
bosis as a cause of disease was carried by his pupils so far that nearly all in- 
flammatory processes were by them attributed to thrombotic changes in 



ETIOLOGY . 



393 



small veins; not only inflammatory lesions, but even tumors were supposed 
to originate in this manner. A now aspect was given to the pathology of 
this disease by the carefnl experimental investigations of Virchow on throm- 
bosis and embolism. He showed that the metastatic deposits always occurred 
at points where vessels had been blocked by an embolus derived from a dis- 
integrating thrombus. In the light of recent research phlebitis precedes 
thrombus-formation at the primary seat of the infection. The pus-microbes 
which are present in the infected tissues permeate the vein-wall and induce 




Fig. 146. — Red Thrombus. Mosaic of Red Corpuscles Traversed by Young Con- 
nective Tissue from the Intima Vessel-wall, Infiltrated by a Few White Corpuscles. 
(Landerer.) 

inflammatory changes characteristic of this form of infection. As soon as 
the infection has reached the intima this structure is roughened, and upon 
the projecting points conglutination takes place, and the foundation for a 
thrombus is laid by a pavement composed of the third corpuscles of the blood. 
Upon this surface aggregation of the colorless corpuscles takes place, and, as 
these structures undergo coagulation-necrosis, fibrin is formed and a red 
thrombus is established. 

The pus-microbes, which have reached the interior of the vein through 
the inflamed vein-wall, multiply in the thrombus, and produce here, as else- 



394 



PRINCIPLES OF SURGERY. 



where under similar favorable circumstances, their specific pathogenic effect. 
The thrombus thus formed is an infected thrombus, which condition pre- 
cludes the possibility of its removal by absorption. With an increase of the 
intravenous infection coagulation is hastened, and a red thrombus soon fills 
the entire lumen of the vein, surrounded by a zone composed exclusively of 
blood-disks, colorless corpuscles, and fibrin, which compose its mural por- 
tion. As soon as the lumen of the vein has been completely obstructed the 
conditions for coagulation are improved, and the thrombus increases in size 
in both directions. The contact of the blood with the dead, infected throm- 
bus results in coagulation, and in this manner layer after layer is added to the 




Fig. 147. — Laminated Thrombus in a Vein. The dark, granular layers are com- 
posed of colorless blood-corpuscles and fibrin; the central, lighter portion, of red corpus- 
cles. 1:97. (Birch-Hirschfeld.) 

thrombus. If thrombus-formation take place in advance of the primary 
phlebitis, inflammation of the vein-wall follows as an inevitable consequence 
from the presence of the infected thrombus, the inflammatory process spread- 
ing, like the infection, from within outward. The growth of a thrombus is 
seldom arrested in a central direction until some large vein-trunk is reached, 
into which the apex of the thrombus projects. 

The blood-current in a vein into which the apex of a thrombus from an 
adjacent vein projects frequently arrests its proximal extension, but if the 
venous circulation is impeded, or the thrombus continues to grow by the 
addition of new layers, in spite of the obstacles presented, one portion after 
another of a vein becomes involved, and the thrombus rapidly increases in 



ETIOLOGI 



395 



length in a proximal direction. A venous thrombus in a pysemic patient is 

only loosely attached to the vein-wall, as the pus-microbes transform the 
white corpuscles, which remain after coagulation has occurred, into pus-cor- 
puscles, and in this manner softening and disintegration of the thrombus are 
accomplished. If a thrombus, at the point where it is in contact with the 
venous circulation on the proximal side, become sufficiently softened, frag- 
ments become detached and are carried away by the venous current as 
emboli. 

Embolism. — An embolus is a detached thrombus, part of a thrombus, or 
any foreign substance transported by the arterial blood-current to its place of 
impaction. The process or act by which this is accomplished is called embolism. 
The obstructed artery and the tissues affected by the interrupted circulation 




Fig. 148. — Thrombophlebitis. A, central ejid of venous thrombus projecting into a 
larger vein-trunk; B, vein-branch not closed by a thrombus. (Billroth.) 



constitute what is known as an infarct. The histology of an infarct as it 
presents itself in the kidney has been recently well described by Eibbert. 
The triangular shape of the infarct is only seen when it involves the cortex 
and medulla; if it is limited to the cortex it is quadrilateral in outline. In 
the small infarcts some of the connective tissue and some of the tubules may 
remain alive. A typical infarct becomes surrounded by three zones: an inner 
and white, due to cell-infiltration; a middle and red, due to hyperemia; 
and an outer or white, due to partial necrosis, in which the nuclei are earlier 
dissolved than elsewhere because of the presence of a lymph-current. The 
hyperaemic zone is due to the influx of blood by way of the capillaries. The 
cellular infiltration is important in so far as it checks the influx of blood; 
the outer zone remains whitish because of the partial necrosis and because 
the circulation is not impeded. An aseptic embolus produces disturbances at 



396 PRINCIPLES OF SURGERY. 

the seat of impaction, which result exclusively from the sudden interruption 
of the blood-supply to the tissues fed by the obstructed vessel. The effect on 
the tissues is the same as though the vessel had been tied with an aseptic 
ligature. Yirchow found that aseptic caoutchouc emboli, introduced into 
the right side of the circulation through the jugular vein, produced no seri- 
ous trouble after their impaction in the branches of the pulmonary artery. 

Panum ascertained, by his experiments, that small, simple emboli in the 
pulmonary artery become encysted. The emboli of foetal cartilage which 
Maas introduced into the jugular vein in dogs did no damage to the pulmo- 
nary tissue, and not only retained their vitality, but became the nucleus of 
a temporary tumor. An aseptic embolus, derived from plastic intravascular 
exudations or an aseptic thrombus, affects the tissues at the seat of impac- 
tion in the same manner as the aseptic substances which have been used to 
produce embolism artificially in animals. An embolus consisting of a frag- 
ment of an infected thrombus, as is the case in pycemia, is a culture-medium 
which contains the same microbes as caused the primary infection, and which 
at the seat -of impaction establishes an independent centre of infection, which 
etiologically and pathologically is identical with the primary invasion. 

The embolic origin of metastatic abscesses was first pointed out by 
Virchow, who, at the same time, showed that the emboli are always derived 
from venous thrombi undergoing puriform softening. The closure of a ves- 
sel by thrombosis is always a slow, gradual process, while the obliteration of 
an artery by an embolus is the work of a moment. The gradual closure of 
a vessel by the slow growth of a thrombus is not attended by the same degree 
of disturbance of nutrition as when a vessel of similar size is suddenly blocked 
by the impaction of an embolus. Septic thrombophlebitis does not lead at 
once to embolism, as new layers are constantly being added to the proximal 
end of the thrombus, from where the fragments which constitute the emboli 
are always derived. Embolism only occurs if the proximal end of the throm- 
bus has become sufficiently softened that fragments separate spontaneously 
and enter the venous circulation, or if the fragments are washed away by the 
venous current from a projecting thrombus. As the infected thrombus is 
always located in a vein within, or in close proximity to, the seat of primary 
infection, the detached fragments or emboli reach the right side of the heart 
with the venous blood, and, as they are usually too large to pass through the 
pulmonary capillaries, they become impacted in the branches of the pulmo- 
nary artery. The lung acts as a filter, and is therefore the most frequent seat 
of embolism and metastatic abscesses. The circulatory disturbances at the 
seat of impaction give rise to pathological conditions which are characteristic 
of embolism, and can be readily recognized in the examination of organs 
after death. The area of tissue affected by the sudden closure of a vessel by 
the impaction 'of an embolus is called an infarct, and the process which pro- 



ETIOLOGY 



:;:i; 



duced the 'pathological changes infarction. Infarcts are usually wedge-shaped, 
the apex of the triangle corresponding to the location of the embolus, and the 
base to the ultimate branches of the obliterated vessel. 

Colmheim lias described what he calls a terminal artery, by which is 
meant one whose branches inosculate only with those of the corresponding 
vein, one which is devoid of collateral anastomosis. Such are the renal and 
splenic arteries, and, in a less complete manner, those of the brain, heart, 
stomach, and lungs. If a terminal artery in the kidney or spleen is ob- 
structed collateral circulation cannot be established, and complete or partial 
necrosis of the tissues which depend on the closed artery for their blood- 
supply is an inevitable consequence. The same result follows embolism of 
a terminal artery in the spleen. In the other organs which have been enu- 
merated the terminal arrangement of the arteries is not as absolute, and 




Fig. 149. — Embolus of Branch of Pulmonary Artery. Hemorrhagic infarction of alveoli. 
Chromic-acid specimen. 1:100. (Birch-Hirschfeld.) 

embolism is not followed by necrosis with the same degree of certainty, as 
circulation can be restored, under favorable cimcumstances, by collateral 
branches. The first effect of the closure of an artery, by an embolus in any 
of these organs, is the appearance of a wedge-shaped area of ischsemia, which 
in size corresponds to the lumen of the vessel obstructed. It may be so small 
that it can hardly be detected by the naked eye, or the base of the wedge may 
be 1 V 2 inches in length. The border of this wedge-shaped space becomes 
the seat of active hyperemia, the surrounding vessels undergoing rapid dila- 
tation. The hyperemia is usually so intense that rhexis takes place and the 
parts become infiltrated with blood; hence the expression hemorrhagic 
infarct. 

Hamilton is of the opinion that the hemorrhagic infarcts in the lung 
are not caused by embolism, but by rupture of small vessels and haemorrhage 



398 



PRINCIPLES OF SURGERY 



into the alveoli, the distribution of the fine branches of the bronchi deter- 
mining the shape of the infarct. Although the ultimate branches of the 
pulmonary artery cannot be called terminal arteries, in the strictest sense 
implied by this term, if they become suddenly blocked by an embolus, col- 
lateral hyperemia is so intense that haemorrhage into the parenchyma of the 
organ frequently takes place: a condition well represented in Fig. 149. 




Fig. 150.— Pysemic Abscess of Lung. A, walls of alveoli; B, effused, small, round 
cells; C, fibrin lying in alveolar spaces; D, cell entangled in meshes of same; E, E, E, 
masses of micrococcus (staphylococcus) lying in exudation. X 350. (Hamilton.) 

In hemorrhagic infarcts of the lung resulting from embolism the tissues 
involved are firmer than normal, and, on section, present pneumonic appear- 
ances, which are due to infiltration with leucocytes and extravasation of 
blood, as well as transudation of blood-plasma through the walls of the hy- 



ETI0L0G1 



399 



peraemic bloods esst Is surrounding the ischsemic area. As the emboli usually 
lodge in the peripheral branches of the pulmonary artery, the infarcts are 
most frequently located near the surface of the lung. Immediately after 
embolism has occurred the district supplied by the obstructed vessel presents 
an anaemic appearance, which soon gives place to a reddish color, resulting 
from the hemorrhagic infiltration. As in pyaemia the embolus conveys from 
the primary seat of infection the specific microbes of suppuration, it becomes 
the centre of a suppurative inflammation (endoarthritis). The pus-microbes 
multiply in their new location and at once induce a suppurative arteritis, 
and, after their passage through the inflamed vessel-wall, they attack the 
histological elements contained in the exudation, which breaks down, be- 




Fig. 151. — Coagulation-necrosis from a Kidney-infarct. A, zone of reactive inflam- 
mation; B, loss of nuclei in the necrosed epithelia. (The nuclei of connective-tissue 
cells are, in part, preserved.) X 300. (Birch-Hirschfeld.) 

comes purulent, and is converted into an abscess. In the lung the leucocytes 
which are present in the infarct are converted into pus-corpuscles, and the 
interstitial connective tissue undergoes necrosis and can be found as detached 
shreds in the abscess. 

Embolism and metastatic abscesses, although most frequently found in 
the lungs in pyaemia, are not limited to this organ. To explain the occur- 
rence of embolism in more remote organs, as the kidneys, spleen, liver, brain, 
etc., we must assume either that an embolus in the pulmonary artery becomes 
the nucleus of a thrombus, which, by its growth, reaches across the pulmo- 
nary capillaries and projects into the pulmonary vein, where fragments again 
become detached and enter the systemic circulation, or zoogloea of pus-mi- 



400 PRINCIPLES OF SURGERY. 

crobes, passing the first filter (the lungs), are arrested in the capillaries of 
distant organs, or, finally, leucocytes impregnated with pus-microbes serve 
as minute emboli, and, after their localization in distant organs, become the 
cause of metastatic suppuration. In the kidney the infarctions appear as 
sharply circumscribed areas of a pale, cream-yellow color. When cut into, 
the infarct has a wedge shape if the medullary portion is involved, the nar- 
row end pointing to the hilus. The red zone is not so marked as in infarc- 
tions of the spleen, and the greatest vascularity is in the direction of the 
embolus. As in infarcts of the lung, the hyperaemic zone corresponds to the 
vessels nearest the ischaemic area. Extravasation of blood, although present, 
is never so marked as in the lung. The epithelial cells within the hyperasmic 
zone are destroyed by coagulation-necrosis, and if the embolus is aseptic this 
portion of the kidney is removed by molecular degeneration and absorption, 
leaving a cicatrix behind. 

Infarcts of the kidney occurring in pyaemia are converted into abscesses 
in the same manner as in the lungs, by the escape of pus-microbes from the 
embolus through the inflamed arterial wall into the tissues starved by de- 
fective blood-supply. 

SYMPTOMS AXD DIAGNOSIS. 

As a wound complication pyaemia never occurs before suppuration has 
taken place, seldom before the seventh, usually about the ninth to eleventh, 
day after the accident or operation, if it is the result of a primary infection 
of the wound. In patients threatened with pyaemia an ill-defined train of 
premonitory symptoms precedes the actual development of the disease. 
These symptoms apply to the appearance of the wound and the general con- 
dition of the patient. The onset of the disease may be suspected at any time 
after suppuration has occurred, when evidences of serious capillary stasis 
manifest themselves at the seat of injury or operation. The thrombophle- 
bitis gives rise to oedema; the margins of the wound appear puffed and ele- 
vated, the granulations pale and flabby; suppuration, which may have been 
profuse, becomes scanty; the pus changes its character, and, instead of a yel- 
lowish, cream-colored fluid, it becomes sanious, serous, or sero-sanguinolent. 

Careful inspection of the parts at this time may reveal the existence of 
thrombosis in one or more of the veins leading from the focus of primary 
infection. The general premonitory s}nnptoms are indicated by a slight de- 
gree of intoxication, the result of the introduction into the circulation of 
pus-microbes and their toxins, from the primary focus of suppuration, caus- 
ing a slight rise in the temperature and a general feeling of malaise, thirst, 
and loss of appetite. The actual development of the disease is initiated by 
a well-marked severe chill or rigor, which lasts from a few minutes to an 
hour or more. The chill resembles a malarial chill, and has often been mis- 



SI MI'TOMS AND Dl ^GNOSIS. 401 

taken and treated as such. Such a chill in a patient suffering from a sup- 
purating wound or abscess is always an alarming symptom. It is an entirely 
subjective symptom, as the thermometer placed in the axilla during the algid 
stage Indicates a rise in the temperature, which often reaches 104° to 105° 
F. before the patient ceases shivering. 

Chills have been artificially produced in animals by the introduction of 
foreign substances into the circulation, and in pyaemia it is an indication that 
fragments of an infected thrombus, and with them a large quantity of pus- 
microbes, have entered the circulation. The chill may recur at regular inter- 
vals daily or every other day: a feature which may still further add to the dif- 
ficulty in making a differential diagnosis between pyaemia and malaria. Usu- 
ally, however, the chill recurs at irregular intervals, — one, two, or three times 
a day, as a rule, — increasing in frequency, and often in intensity, as the dis- 
ease progresses. If, for instance, during the first few days the patient has 
one chill daily, and, after a few days two or more during the same time, every 
additional chill indicates a more advanced stage of intoxication, and an in- 
crease in the number of metastatic foci. After the chill the fever continues 
for several hours, with a temperature of 103° to 104° F., until the appear- 
ance of profuse perspiration, when the temperature falls to normal, or even 
a little below that. The chill, fever, and sweating coming in the same order 
and of about the same duration as in malaria, the clinical picture resembles 
the latter almost to perfection, and on this account many cases of pyaemia 
have been mistaken in the beginning for malaria, and vice versa. 

The fever which attends pyaemia always is of an intermittent or remit- 
tent type. In acute pyaemia the chills may return several times during 
twenty-four hours, the temperature between them showing remissions, but 
seldom returning to normal. In subacute and chronic cases the remissions 
are well marked between the chills, the temperature often sinking below nor- 
mal. Yomiting and diarrhoea are less constant symptoms than in septicaemia. 
The pulse in its frequency corresponds to the temperature; its force is always 
reduced by the depressing effect of the toxins upon the heart. Delirium is 
occasionally present, but, as a rule, the mind is clear until the end. The yel- 
lowish color of the skin, almost constantly present in pyaemia, has been at- 
tributed to icterus, resulting from metastatic processes in the liver; but in 
the majority of cases it is not the result of retention and absorption of bile, 
but is caused by destruction of red blood-corpuscles and pigmentation of the 
tissues with the coloring material thus liberated. It is an icterus, which, on 
account of its origin, is called "hcematogeiwus icterus" The metastatic de- 
posits in the kidneys are indicated by the appearance of albumen and some- 
times pus in the urine. 

Metastatic Suppuration. — Infarcts in one or more of the internal organs 
are present in every case of pyaemia, and suppuration in some of the large 



402 PRINCIPLES OF SURGERY. 

cavities is of frequent occurrence. In reference to the number of secondary 
metastatic foci of suppuration, a great deal depends on the clinical form 
the disease assumes. In the acute variety, which proves fatal within one 
to three weeks, the infarcts are numerous and the abscesses quite small, while 
in some of the infarcts the existence of suppuration cannot be demonstrated 
macroscopically. In chronic pyaemia, in which life is prolonged for months, 
and sometimes even a year, the number of secondary foci are few, but they 
have resulted in the formation of large abscesses. The presence of infarcts 
of the lung are indicated by symptoms and signs which point to circum- 
scribed foci of inflammation in this organ. If the infarct is immediately un- 
derneath the pleura, it gives rise to circumscribed pleuritis and sharp, lan- 
cinating pain at a point corresponding to the location of the infarct, always 
aggravated by the respiratory movements. In such cases friction-sounds can 
often be heard over the infarct. The consolidation of the tissues involved by 
the infarct by inflammatory infiltration from the vessels surrounding it is 
attended by crepitant rales, bronchial breathing, and dullness on percussion, 
over an area corresponding to the size of the infarct. A pulmonary abscess 
which takes the place of an infarct increases in size by encroaching upon the 
surrounding tissues, and in chronic cases may empty itself into a bronchial 
tube. A subpleural infarct, infected with pus-microbes, not infrequently 
leads to suppurative pleuritis and empyema by the extension of the infection 
from the lung-tissues to the adjacent pleura. In the same manner a suppu- 
rating infarct of the lung may become a direct cause of suppurative pericar- 
ditis, and pyopericardium if its location is adjacent to the pericardium. The 
onset of metastatic foci in the lungs is often insidious, and even large infarcts 
often occasion only slight subjective symptoms and objective signs. Em- 
barrassed breathing should admonish the attendant to search for evidences 
of multiple infarcts of the lung. Abscesses in the liver, caused by septic 
emboli, vary in size from that of a pea to an orange, but occasion no symp- 
toms unless they are located immediately underneath the serous covering, 
when they cause localized pain. Embolic infarcts in the kidneys may be sus- 
pected if the urine contains albumen or pus, or both. The spleen is always 
enlarged in pyaemia, but, as this is the case in all acute infective processes, 
the presence of an infarct or abscess is only to be suspected if the symptoms, 
especially pain and circumscribed tenderness, point to the existence of peri- 
splenitis. Enormous pyaemic abscesses often develop insidiously and with- 
out pain, or the ordinary symptoms of acute inflammation between muscles 
and in the subcutaneous connective tissue. Metastatic suppuration in py- 
aemia takes place not only where infarction has occurred, but also in localities 
where the existence of embolism cannot be demonstrated anatomically, this 
being notably the case in joints and the large serous cavities. Suppurative 
pericarditis, pleuritis, and peritonitis frequently complicate acute, rapidly- 



SYMPTOMS AND DIAGNOSIS. 403 

fatal pyaemia. Suppurative synovitis, multiple or limited to one joint, is a 
frequent complication, both in acute and chronic pyaemia. Metastatic sup- 
puration in these localities develops without demonstrable infarcts, and oc- 
curs, in all probability, in consequence of mural implantation of pus-mi- 
crobes or infected leucocytes upon the wall of capillary vessels, the intima 
of which has been damaged by toxins held in solution by the circulating 
blood. As in all cases of pyaemia pus-microbes and their toxins necessarily 
constantly enter the circulation from the primary focus of infection, they 
prepare the soil for the reception and pathogenic action of pus-microbes in 
the vessels and tissues of certain organs, more especially the synovial mem- 
brane of joints and the serous membranes lining the large cavities. Pyaemic 
abscesses, when well developed, always contain yellow pus of the consistence 
of cream. Examined under the microscope, such pus contains corpuscles 
in which no sio-n of a nucleus can be found. 



Fig. 152. — Pyasmic Pus, showing Complete Nuclear Destruction in Corpuscles and an 
Abundance of Pus-microbes within and between Pus-corpuscles. (Landerer.) 

The pus-microbes are always present in great numbers, both within the 
pus-corpuscles and in the pus-serum. While some doubt may remain after 
the first chill as to the nature of the disease, this doubt is dispelled with the 
recurrence of the chills. In acute cases the chill returns once or twice daily, 
but, unlike in cases of malaria, if the chill is of daily occurrence, it does not 
come at a fixed time, as is the case in the latter. If the disease does not 
culminate into a daily chill, the temperature then shows an irregular remit- 
tent type of fever. The patient loses strength and flesh rapidly, and the face 
presents the color of a mixture of the hectic flush with the icteric hue. While 
the pulse at first rises only to 100 to 120 beats per minute during the febrile 
exacerbations, it soon remains at from 120 to 150 per minute. Great thirst 
and complete loss of appetite remain constant symptoms. The tongue and 
lips are dry, diarrhoea is more common as septic intoxication advances, and 
the stools are frequently stained with blood. As the fatal termination ap- 
proaches, delirium and sopor come on, and under increasing symptoms of 
depression death takes place gradually from heart-failure, or suddenly from 
embolism of the pulmonary artery. In chronic cases the duration of the dis- 



404 PRINCIPLES OF SURGERY. 

ease is sometimes prolonged for months, and Billroth relates a case where the 
patient lived for a year. In chronic cases the chills recur at long intervals, 
and the fever assumes a remittent type between them. In still another class 
of chronic pyaemia the chills ultimately disappear, and the fever assumes a 
mild, continuous type, while the patient gradually succumbs to decubitus, 
amyloid degeneration of internal organs, or a slow form of septic intoxica- 
tion. 

PROGNOSIS. 

The prognosis of pyaemia is always grave. Acute pyaemia, in spite of all 
treatment, almost without exception terminates in death in from one to two 
weeks. The few recoveries which have been reported were cases of subacute 
or chronic pyaemia. As pyaemia is not a primary, but secondary, condition, 
it is a fatal disease from. the very beginning, as during its commencement 
transportation of infected tissue has taken place to localities usually inac- 
cessible to radical treatment. In acute cases death seldom takes place before 
the end of the first week, more frequently from the second to the end of the 
third week. Chronic cases not complicated by pulmonary infarcts, the 
metastatic suppuration in parts accessible to surgical treatment, are occasion- 
ally amenable to successful treatment, and a cure can be obtained after a long 
and lingering illness. Prospects of a successful issue in chronic cases can be 
only entertained when the disease attacks young individuals otherwise in 
good health. The prognosis of pyaemia is also modified by the location of 
the primary focus of infection, as when this is not accessible to direct treat- 
ment the disease will progress uninfluenced by general treatment. If, on 
the other hand, further supply of septic material from the primary infection- 
.atrium can be prevented by a prompt removal of the infected tissues, one of 
the most important indications of treatment has been met, and the hope of 
a favorable termination has been thereby increased. 

PATHOLOGICAL ANATOMY. 

The pathological changes found in patients who have died of pyaemia 
are characteristic. The primary focus of infection may no longer be present, 
as it may have healed, but, as a rule, this has not occurred, and examination 
shows a suppurating wound, an abscess, an osteomyelitic focus, a suppurating 
phlebitis or sinus phlebitis. The vein in which the fatal thrombus formed 
may not be a large one; indeed, it may be so small as to elude detection by 
macroscopical examination. If the immediate cause of the pyaemia, the 
thrombosed vein, can be located, it will be found filled with a softened, loose 
blood-clot, which is very variable in length, and the proximal end of which 
projects usually into the lumen of some larger vein-trunk on the proximal 
side. The vein-wall itself is in a state of suppurative inflammation that pre- 



P \ rSOLOGICAL w \ tom Y. L05 

vents t hi' formation of firm adhesions between the thrombus and the intima, 
as we find it in cases of plastic thrombophlebitis. The new histological ele- 
ments thai are produced by the inflammatory process are at once converted 
into pus-corpuscles, and some of these are distributed through the substance 
of the blood-clot, and furnish an additional cause for the softening and dis- 
integration of the coagulum. The infarcts are most numerous in the lungs, 
but are also found in the spleen, kidneys, and liver. An embolus catches in 
an artery at a point where the lumen suddenly becomes smaller, which is the 
case where the vessel bifurcates. The embolus, after it has become impacted, 
becomes the nucleus of a thrombus, as the blood which comes in contact with 
it undergoes coagulation, and in this manner layer after layer is added on 
each side. As the embolus under these circumstances is always composed of 
dead, infected material, it causes, at the seat of impaction, a specific inflam- 
mation, which, in every respect, represents the type of inflammation at the 
primary seat of infection. As the tissues which are in immediate contact with 
the embolus are the coats -of an artery, a suppurative arteritis follows tlie im- 
paction, and, as soon as the pus-microbes have passed through the softened, 
inflamed arterial wall, the infection extends to the tissues weakened by the 
sudden abstraction of blood; that is, the tissues which are within the borders 
of the wedge-shaped infarct. The hypersemic zone around the infarct con- 
stitutes a wall of protection against unlimited extension of the infection and 
inflammation. In the lungs the infarct becomes rapidly infiltrated with the 
products of inflammation from the hyperamiic zone, which gives rise to con- 
solidation of that portion of the lung. Suppuration is attended by liquefac- 
tion of the exudation, and the infarct is transformed into an abscess. 

In pyaemia the emboli that reach the systemic circulation are smaller 
than those which reach the pulmonary artery; consequently the infarcts, as 
a rule, in the kidney, spleen, liver, and other distant organs are smaller than 
those in the lungs. In metastatic suppuration without embolism, in the 
strict sense in which this word has been heretofore used, the pus-microbes 
which become implanted upon capillary walls, changed by the action of 
preexisting toxins diffused in the blood, reach and infect the paravascular 
tissues and the interior of large cavities, thus causing a rapidly-spreading, 
diffuse, suppurative inflammation. In metastatic suppurative inflammation 
of the s}'novial membrane of joints, the peritoneum, pleura, and pericardium, 
the process represents all the essential features of a specific surface inflam- 
mation, characterized by rapid extension of the inflammation over the whole 
surface and the accumulation of a large, purulent collection in a short time. 
Microscopical examination of nearly all organs in fatal cases of pyaemia re- 
veals the existence of coagulation-necrosis resulting from the action of pus- 
microbes and their toxins upon tissues with which they have been brought 
in direct contact. The spleen is always enlarged and softened, even if no 



406 PRINCIPLES OF SURGERY. 

infarcts are present. The heart is flabby and the muscular tissue softened. 
The intestinal mucous membrane is swollen, vascular, softened, and at points 
shows submucous extravasation from rupture of capillary vessels, — evidences 
that this structure has also become the seat of metastatic inflammation. Em- 
bolism of cerebral vessels is an unusual occurrence in pyaemia, while they are 
frequently obstructed by emboli which become detached from valvular vege- 
tations in the left side of the heart. 

TREATMENT. 

Before the use of antiseptics in surgery pyaemia figured largely as the 
cause of death after injuries and operations. Only thirty years ago a large 
percentage of the surgical patients in the old, infected, European hospitals 
died from this disease. Insignificant injuries and minor operations were fre- 
quently followed by this fatal complication. At present it is a source of pride 
to the teachers of surgery if, during a course of lectures, they do not succeed 
in finding a case for clinical study and instruction. In hospitals where anti- 
septic surgery is thoroughly and conscientiously practiced the disease is al- 
most unknown. Helpless as we still are in curing the disease, as surely can 
we prevent it, in the management of recent injuries or intentional wounds, 
if we resort to careful and efficient antiseptic and aseptic precautions. The 
prevention of suppuration in a wound furnishes absolute protection against 
pyaemia. Again, the early radical treatment of suppurative lesions has been 
the means of diminishing the frequency of pyaemia from causes other than 
wounds. The prophylactic treatment of pyaemia consists in preventing sup- 
puration in wounds by antiseptic means, and in sterilizing suppurating foci 
before septic thrombophlebitis has occurred by early incision, antiseptic irriga- 
tion, drainage, and in maintaining asepticity under antiseptic dressings. 

In the treatment of suppurating wounds a great deal can be done toward 
the prevention of pyaemia by resorting to thorough secondary disinfection, 
and in guarding against tension and accumulation of the products of septic 
inflammation by efficient drainage, or, still better, by combining drainage 
with permanent irrigation. Suppurative osteomyelitis should be treated by 
early operative measures, not only for the purpose of preventing unnecessary 
destruction of bone and of relieving pain, but more particularly with a view 
of warding off this fatal complication. Klebs made the suggestion to sur- 
geons that the prophylactic treatment of pyaemia should be carried still 
further, by excising such veins as are known to contain infected thrombi be- 
fore embolism has taken place. The same suggestion was made by Zaufel 
in 1880, who proposed ligation of the internal jugular vein as a prophylactic 
measure against pyaemia in cases of phlebitis of the lateral sinus complicating 
septic inflammation of the middle ear. To Lane belongs the credit of hav- 
ing first applied this suggestion in practice. The justifiability and advis- 



TBEATMEH I . LCJ 

ability of such treatment cannot be doubted, and surgeons will be glad to 
adopt this suggestion in eases where it is possible to ascertain the location 
of the thrombosed vein or veins, and where such an operation is feasible on 
anatomical grounds. A number of successful curative operations have been 
performed during the last few years in cases of incipient pyaemia following 
thrombophlebitis of the sigmoid sinus in cases of suppurative inflammation 
of the middle ear. The operation consists in ligating the internal jugular 
vein on the corresponding side below the thrombus if this has extended to 
the vein, and in exposing and removing the suppurating thrombus from the 
sinus. This operation should be performed in every case of suppuration 
of the middle ear as soon as this complication can be recognized. Salzer 
operated on two such cases by opening the lateral sinus and removing the 
septic thrombus, and one of his cases recovered. Keen in addition ligated 
and divided the internal jugular vein on the corresponding side below the 
thrombus which had formed in it, but his patient died. The most charac- 
teristic s}miptoms of septic thrombosis of the lateral sinus are: tenderness 
along the course of the internal jugular vein, evidences of disturbed circula- 
tion in the region of the ear, and, if the thrombosis has extended to the in- 
ternal jugular vein, emptiness of the vein below the thrombus. Puncture 
with the needle of an hypodermic syringe will show at once whether the 
lumen of the sinus is occluded. In grave cases of osteomyelitis an opera- 
tion for this special indication would often make it necessary to amputate, 
as even the most thorough scraping out of the infected medullary cavity 
might fail in removing all of the infected thrombi. It has also been sug- 
gested to interrupt the venous circulation in one of the principal venous 
trunks of a limb by ligation, for the purpose of preventing mechanically the 
entrance of detached fragments of a thrombus into the circulation; but this 
procedure has not answered the expectations, as the emboli will reach the 
general circulation through collateral branches. Eemoval of the infected 
thrombi by amputation or resection of the affected portion of a vein are 
more reliable prophylactic measures than ligation in the continuity of a 
principal vein-trunk on the proximal side of the primary seat of infection. 
Detachment of fragments of a disintegrating thrombus must be prevented as 
far as possible by securing absolute rest for the infected part, as all sudden 
movements, active and passive, and sudden disturbances of the circulation 
may become the means of separation of fragments, and their transportation 
as emboli into the circulation. The curative treatment of pyaemia, medical 
and surgical, is unsatisfactory. Quinine, natrum benzoicum, and the dif- 
ferent preparations of salicylic acid have been used quite extensively in the 
treatment of the fever which attends the disease. Antifebrin, antipyrin, 
and other drugs of the same class of remedies are worse than useless, as the 
favorable effects from their antipyretic action are more than overbalanced by 



408 PEINCIPLES OF SURGERY. 

the harm they do in depressing the action of the heart. External heat and the 
internal administration of diffusible stimulants should be used to shorten 
the duration of the rigors. Alcohol stimulants are indicated in the acute and 
chronic forms of the disease. 

In chronic pyaemia a daily tepid bath is of the greatest value. In the 
same class of cases it is of the utmost importance to support the patient's 
strength by systematic feeding and the use of the malt beverages, such as 
beer, ale, and porter, with a view of prolonging life until the microbic cause 
is eliminated from the primary and secondary depots of infection, spontane- 
ously or by surgical treatment. In acute cases of pyaemia, originating from 
a wound of one of the extremities, or from acute suppurative osteomyelitis 
of the long bones, the question of removal of the primary focus of infection 
by amputation will present itself. 

If, from a study of the symptoms, it become apparent that multiple 
infarcts exist in the lungs, and other organs, amputation is not permis- 
sible, as it would only result in shortening the life of the patient. The 
propriety of an amputation should only be considered in the beginning of the 
disease, and before extensive dissemination of tlie purulent infection by em- 
bolism has taken place. In a suppurating, compound fracture, amputation 
may be indicated for other reasons than those of a threatened or developed 
attack of pyaemia. Secondary disinfection of a suppurating wound with ex- 
cision <of thrombophlebitic veins, where this is possible, should be practiced 
in all cases of pycemia for the purpose of preventing or limiting general dis- 
semination by embolism. In chronic cases the secondary metastatic proc- 
esses should receive early and careful attention. 

As in these cases the metastatic suppuration, as a rule, is not caused 
by embolic infarcts, life is threatened by the secondary lesions, from which 
intoxication is maintained, and from which new places may become infected 
by localization of pus-microbes in capillary vessels weakened by the action 
of toxins. If the metastasis is limited to one or more joints and the disease 
pursue a chronic course, very satisfactory results can be obtained by tapping 
and washing out the joints with a 3-per-cent. solution of carbolic acid. The 
tapping and irrigation should be repeated as often as the effusion returns. 
In a case of genuine pyaemia following a gunshot wound of the leg, compli- 
cated by secondary haemorrhage and gangrene, that recently came under my 
observation, I performed amputation and later tapped both shoulder-joints 
and the left sternoarticular joint repeatedly and followed the tapping in each 
instance by antiseptic irrigation. The patient finally recovered, and the 
joints thus treated were movable. For thirty-five days he consumed, on an 
average, a quart of whisky daily, and I attribute the favorable result largely 
to this energetic stimulation. Suppurating joints are incised, drained, and 
irrigated under strict antiseptic precautions, and, if the metastatic suppura- 



SEPTOn i:\HA. -109 

tion is limited to a Bingle joint, this can be done with a fair prospect of a 
favorable result. Purulent collections in the serous cavities or connective 
tissue arc dealt with in a similar manner. Careful attention to diet and the 
sanitary surroundings of the patient, combined with energetic surgical treat- 
ment of the suppurating foci, will, at least occasionally, be rewarded by an 
ultimate recovery. 

SEPTOPYiEMIA. 

In the absence of more accurate knowledge concerning the microbic 
cause of septicaemia, we must, at least for the present, assign to septicaemia 
and pyaemia the same bacteriological cause. That pus-microbes can produce 
septicaemia when introduced into the circulation in sufficient quantity has 
already been shown, and that pus-microbes have been frequently cultivated 
from septic products is a matter of demonstration; hence the disease, if not 
identical with pyaemia, from a bacteriological stand-point, is at any rate 
closely allied to it. It has also been shown that, in case the life of a septic 
patient is prolonged for a sufficient length of time, the metastatic foci of 
inflammation are the seat of incipient suppuration; hence such cases re- 
semble pyaemia upon a pathological basis. In pyaemia, after cessation of the 
rigors, which are the most characteristic clinical symptom of this disease, the 
fever resembles septicaemia, and, as the clinical picture thus developed rests 
upon pathological conditions typical of pyaemia, it would be proper to apply 
to such cases the term septopycemia. For the same etiological and patho- 
logical reasons we apply the same term to septicaemia in which post-mortem 
examination reveals the presence of minute, multiple, suppurating foci. 

Septopyaemia may be defined as a condition in which the symptoms 
indicate the presence of both septicaemia and pyaemia and in which the post- 
mortem appearances point to septic and purulent infection. Leube de- 
scribed such a combination of the two diseases, which as yet are considered 
as distinct, occurring in patients in whom he was unable to trace the source 
of infection from without; hence he called the affection spontaneous sep- 
tico-pycemia. Litten, on the other hand, in similar cases, was always able to 
locate the infection-atrium, but the primary infection at the time acute 
symptoms set in had either disappeared or its location could only be ascer- 
tained by most careful examination. Jiirgensen applied to these cases the 
lengthy compound word "kryptogenetic-septico-pycemia" as he was unable 
to find a tangible infection-atrium. In an article on the subject he gives 
an account of 100 cases that came under his own personal observation. The 
patients were usually attacked first with acute pharyngitis, and, as this stage 
was generally attended by a chill and a general feeling of malaise, the pa- 
tients usually attributed the onset of the disease to exposure to cold. In most 
cases the general infection was announced by a severe chill. Eapid loss of 



410 PEINCIPLES OF SURGERY. 

strength was one of the most prominent symptoms; the patients in a few 
hours after the chill became utterly prostrated. The symptoms which 
pointed to local processes during life were referred most frequently to the 
lungs, liver, spleen, pleura, heart, and the long bones. Whether the primary 
affection occurred through the pharynx, where the first symptoms were 
manifested, could not be definitely ascertained. In the acute cases the symp- 
toms were grave from the beginning and increased in intensity as the infec- 
tion progressed, while, in the chronic cases, infection is kept up from some 
suppurating focus, and the disease may continue for several years. Subcu- 
taneous and retinal hemorrhagic extravasations were frequently observed. 
Post-mortem examinations revealed suppuration in some of the internal or- 
gans, and vascular changes which are characteristic of sepsis. 

These cases may be compared with acute suppurative osteomyelitis, 
where, after the most careful inquiry and the most scrutinizing examination, 
we often fail in furnishing reliable evidence for locating the primary source 
of infection. It is possible that the pus-microbes enter through an intact 
or inflamed mucous membrane, or through the appendages of the skin, and 
that they remain in a latent, inactive condition until a weak point is created 
somewhere in the body, where they localize in a soil prepared for their re- 
production and pathogenic action; or, what is more likely the case, they 
enter through an abrasion or slight lesion, which may be so insignificant 
that the patient himself fails to notice it, and produce no symptoms until, 
by accident or disease, a proper soil is prepared for the initiation of an acute 
attack in one or more of the internal organs. The remote dangers which 
may follow infection through an insignificant wound, or from a small, sup- 
purating focus, should remind the surgeon of the importance of treating 
these little ailments with the necessary care and attention, and by so doing 
he will often be the means of preventing fatal complications. In two cases 
of cryptogenetic septopyasmia that have come under my own observation 
the disease was complicated by ulcerative endocarditis. In one of these cases 
the immediate cause of death was gangrene from embolism of the popliteal 
artery. 



CHAPTER XVI. 

Erysipelas. 

Erysipelas is a self-limited, acute, non-suppurative inflammation of 
the lymphatic vessels of the skin or mucous membrane, attended by redness 
and a continued type of fever. As a wound complication it occurs independ- 
ently of suppuration, and in its uncomplicated pure form remains as a super- 
ficial affection, the inflammation never passing beyond the structures of the 
skin or mucous membrane. 

HISTORY OF ITS MICROBIC ORIGIN. 

The contagiousness of erysipelas has been recognized for centuries, and 
on this account early attempts were made to include it among microbic dis- 
eases. In 1868 Hueter maintained that erysipelas and hospital gangrene 
were identical diseases and caused by the same microorganism. Its microbic 
nature was again made the subject of investigation in 1872, when Nepveau 
discovered micrococci in the blood of erysipelatous patients. Wilde detected 
the same microbes in the blood, but asserted that similar microorganisms 
could be found in the pus in wounds from which the erysipelas developed. 

In 1874 Recklinghausen found masses of micrococci in the lymphatic 
channels in the inflamed skin at the border of an erysipelatous inflammation. 
Xearly the same time similar observations were made by Billroth, Ehrlich, 
Tillmanns, and Koch. Tillmanns produced the disease artificially in ani- 
mals by injecting subcutaneously the serum contained in the bullae of ery- 
sipelatous skin. 

Koch attempted to produce the disease artificially in rabbits with in- 
jections of different putrid fluids, but failed until he made inoculations with 
mouse-dung softened in distilled water. He injected the material under the 
skin of the ear, and produced an inflammation which in its course resembled 
erysipelas. The swelling and redness spread slowly downward from the point 
of inoculation. On the fifth day it had extended as far as the root of the 
ear. The ear became exceedingly vascular, so that the separate vessels could 
no longer be identified, while the tissues were softened and cedematous. The 
animal died on the seventh day. Blood taken from the heart of this animal 
produced no effect in other rabbits. No microbes could be found in the 
blood or in any other organ except the affected ear. In transverse sections 
of the ear the blood-vessels were seen to be markedly dilated, full of red 
corpuscles, and surrounded by the nuclei of white corpuscles. Between these 
and the cartilage-cells bacilli were found. 

The bacilli were present close to the cartilage only. Here they were 

(411) 



412 



PRINCIPLES OF SURGERY. 



found in large clusters, from which the bacilli radiate in all directions. This 
net-work of bacilli extended over the whole cartilage of the ear on both sur- 
faces. Inflammation was most marked in the vicinity of the bacilli, and, 
consequently, in the absence of other causes, there could l»e no doubt that 
the erysipelatous inflammation was caused by these microbes. Orth found 
micrococci in the contents of the bullae of erysipelas. Eecklinghausen and 




7 / i' 



// 



Fig. 153.— Section of Ear of Rabbit Parallel to Surface of Cartilage. The morbid 
process resembled erysipelas. A, ball-like accumulation of bacilli; B, accumulation of 
nuclei above the layer of bacilli; C, nuclei of flat cells connected with the cartilage 
below the layer of bacilli; D, bacilli arranged parallel to each other. X 700. (KocJt.) 1 



Lukowsky found them in the lymphatic vessels and the connective-tissue 
spaces in the structures affected by erysipelas. Billroth and Ehrlich found 
bacteria not only in the lymphatic channels, but also in the blood-vessels of 
the inflamed skin. Tillmanns found microbes in erysipelatous skin, and Let- 



1 Copied from 
Society, London. 



'Traumatic Infective Diseases," by permission of the New Sydenham 



CULTIVATION. U3 

zerich, in cases of erysipelas attacking vaccination wounds, J'ound them in 
the wound itself, in the blood-vessels, muscles, liver, spleen, and kidneys. 
The essential specific cause of erysipelas was finally discovered by Fehleisen 
in L883. He cultivated the microbe from erysipelatous products, and dem- 
onstrated its essential etiological relationship to erysipelas by producing the 
disease artificially, in animals and man, by inoculations with pure cultures. 
From the morphological appearance of the. microbe and its direct etiological 
bearing to erysipelas he called it the streptococcus of erysipelas. With pure 
cultures of this microbe he produced by inoculations not only erysipelas in 
animals, to prove its specific pathogenic qualities, but successful inoculations 
were also made in man for therapeutic purposes. 

DESCRIPTION OF STREPTOCOCCUS ERYSIPELATOSUS. 

The streptococcus erysipelatosus, discovered by Fehleisen, when exam- 
ined under the microscope appears in the form of chains, the links of which 
are minute cocci, 3 to 4 micromillimetres in diameter. 



c . 


.••• V 




o 




*.../ 






\ 




.• J 


'V 






/ 


: 






IW 


('" 




\ 


"3 




'\ 


/*"j 






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•♦.- 


*' (} 


A, 


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....• 






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Fig. 154. — Streptococcus Erysipelatosus. Pure culture in bouillon at 37° C, 
stained with fuchsin. X 950. (Baumgarten.) 

The streptococcus of erysipelas invades the superficial lymphatic chan- 
nels of the skin or mucous membrane exclusively, but it can also be found 
in the serum contained in bullae. Each coccus, when it is about to divide, 
becomes larger and oval, and soon appears made up of two hemispherical 
masses, the two new cocci resulting from fission of the old one. Morpho- 
logically, the streptococcus of erysipelas and the streptococcus pyogenes are 
nearly identical, only that the cocci of erysipelas are .somewhat larger, while 
both are somewhat smaller than the staphylococci. 

CULTIVATION. 

This microbe can be readily cultivated in bouillon at ordinary room- 
temperature; also upon gelatin, agar-agar, and solidified blood-serum. Upon 
solid nutrient media the appearances of the cultures resemble very strongly 
those of streptococcus pyogenes. There is less tendency, however, to the 
formation of terraces, the margin is thicker and more irregular in outline, 
and the appearance of the growth is more opaque and whiter. Eosenbach 
mentions, as another distinguishing feature between the two, that the culture 



414 



PRINCIPLES OF SURGERY. 



of the streptococcus of erysipelas represents the shape of a fern, while the 
outlines of the cultures of the pus-streptococcus describe the shape of an 
acacia-leaf. The culture appears as a very delicate grayish-white film. The 
growth is very slow, and the individual colonies remain small. The strepto- 
coccus of erysipelas does not liquefy gelatin. The microbe of erysipelas 
grows equally well when oxygen is excluded. If gelatin is inoculated by 
puncturing with a needle charged with a pure culture, microscopical colonies 
can be seen the whole length of the track of the needle at the end of twenty- 
four hours. In four days the culture has reached the height of development, 




Fig. 155.— Stab Culture of Streptococcus of Erysipelas in Gelatin at Ordinary- 
Temperature of Room. Four days old. Natural size. (Baumgarten.) 

and colonies the size of a grain of sand to that of a pin's head occupy the 
whole length of the needle-track. 

In cultures the microbe retains its pathogenic qualities for about four 
months. 



IXOCULATIOX EXPERIMENTS. 

Fehleisen produced, artificially, typical erysipelas in rabbits by inject- 
ing pure cultures under the skin of the ear. Koch and Gaffky used cultures 
grown upon solidified blood-serum and inoculated 9 rabbits. In 8 of these 
typical erysipelas developed, the attack lasting from six to twelve days. 

Krause obtained positive results by inoculating gray mice. In all cases 



initiation FOB THERAPEUTIC PURPOS 415 

where the inoculation proved successful the erysipelatous inflammation 
Btarted a1 the point of inoculation, and extended rapidly, always following 
the lymphatic channels. In Ivrause's experiments the animals died after 
three or four days, even when only a minute quantity of the culture was in- 
jected under the skin of the back. Examination of the infected tissues after 
death showed that the inflammation followed the invasion of the microbes, 
and consequently the principal pathological changes were found within and 
in the immediate vicinity of the lymphatic channels. 

INOCULATION FOR THERAPEUTIC PURPOSES. 

As soon as it was demonstrated experimentally that simple, uncompli- 
cated erysipelas is a disease attended by but little danger to life, the sug- 
gestion was near that, if the disease could be artificially produced in man 
by inoculation with pure cultures, the local and general conditions thus pro- 
duced might prove useful in the cure or amelioration of some diseases not 
amenable to operative treatment and internal medication. Of 7 persons the 
subjects of inoperable malignant tumors, inoculated by Fehleisen with pure 
cultures, 6 developed typical erysipelas; in the seventh case the patient had 
passed through an attack of erysipelas only a few weeks previously, and was, 
in all probability, still protected against a new attack. This patient was in- 
oculated a second time with a negative result. In other instances a second 
inoculation failed after a successful inoculation. The period of incubation 
was fixed at from fifteen to sixty-one hours. The microbe was found only 
in the lymphatic vessels and connective-tissue spaces, and when the culture 
was pure suppuration was never produced. Fehleisen has seen, by this treat- 
ment, a cancer of the breast become smaller, a lupus disappear almost com- 
pletely, while a case of fibrosarcoma and another of sarcoma were not mate- 
rially affected by this method of treatment. Janicke and Neisser have re- 
corded a death from erysipelas thus intentionally produced in a case of 
cancer of the breast beyond the reach of an operation. At the necropsy it 
was proved that the tumor had almost completely disappeared, and the mi- 
croscopical examination of portions that had remained appeared to show that 
the tumor-cells had been destroyed through the direct action of the microbes. 
Biedert saw, in a child suffering from a sarcoma involving the posterior part 
of the cavity of the mouth and pharynx, the left half of the tongue, the 
naso-pharyngeal space, and the right orbit, the tumor disappear almost com- 
pletely during an attack of erysipelas. Cases, on the other hand, have been 
reported in which, after an accidental or intentional attack of erysipelas, the 
tumor commenced to grow more rapidly. Xeelsen reports a case of car- 
cinoma of the breast, in which, after two severe attacks of erysipelas, the 
tumor not only commenced to grow faster, but at the same time the regional 
infection progressed also more rapidly. 



416 PRINCIPLES OF SURGERY. 

Schwimmer gives an account of 11 cases of lupus in all of which no 
improvement was observed after an intercurrent attack of erysipelas. In a 
case of keloid an attack of erysipelas was followed by marked improvement, 
and a lipoma underwent a similar favorable change from the same cause. 
Syphilitic lesions he saw temporarily benefited, while the erysipelas had no 
effect in permanently influencing the course of the disease. 

Brims gives an account of the effect of erysipelas on tumors in 22 pa- 
tients. Among these, 3 cases of sarcoma were permanently cured. Two cases 
of multiple keloid after burns were also cured. In 4 cases of lymphoma of 
the neck some of the glands became smaller and some disappeared. In 5 
cases the erysipelas was artificially produced by inoculation with a pure cult- 
ure. In 3 cases of carcinoma of the mamma 1 was not influenced by the 
disease, 1 became one-half smaller, and 1 was reduced to a small induration 
in the scar, the size of a pea. A multiple fibrosarcoma was greatly bene- 
fited, while an orbital sarcoma was not improved. 

Coley has made extensive use of a combined sterile culture of the strep- 
tococcus of erysipelas and the bacillus prodigiosus in the treatment of in- 
operable malignant tumors. From his published reports it appears that a 
number of cases of sarcoma were permanently cured. The writer has given 
this treatment a faithful trial in more than fifty cases of inoperable malig- 
nant tumors during the last few years, with uniform negative results. In 
some of these cases the reaction was so intense that the general health was 
much impaired by the treatment. 

In view of the uncertainty of the result, and the not inconsiderable 
danger which attends the intentional form of erysipelas in patients debili- 
tated by antecedent disease, it is safe to predict that no further inoculations 
will be made in man until, perhaps, future research will demonstrate a cer- 
tain specific antagonistic action of the streptococcus of erysipelas against 
some other pathogenic microbes the cause of grave diseases not amenable to 
successful treatment by less heroic measures. 

MANNER OF INFECTION. 

An intact skin or mucous membrane furnishes absolute protection 
against infection with the streptococcus of erysipelas. This microbe cannot 
reach the lymphatic vessels without an infection-atrium, which may be a 
small abrasion, a wound, blister, ulcer; in fact, any breach of continuity in 
the skin or mucous membrane. Before antiseptic surgery was practiced in- 
fection frequently occurred through accidental or intentional wounds. C. 
W. Allen says that in 50 per cent, the entrance of infection is through some 
skin defect. In 9 out of 100 cases the disease commenced in the pharynx, 
in 3 it was due to a nasal catarrh, and in 1 a lacrymal fistula served as an 
avenue of infection. Antiseptic surgery has greatly diminished the fre- 



MANNEB OF INFECTION. 417 

quency of traumatic erysipelas, but lias not completely eradicated it, as an 
occasional case will occur in the hands of the most careful aseptic surgeons. 
Even before the microbic cause of erysipelas was known, Trousseau, one of 
the closest of clinical observers, claimed that infection with the virus of 
erysipelas is only possible through some wound or abrasion of the skin; the 
Latter may be so insignificant as to be unnoticeable and entirely overlooked 
by both patient and physician. Idiopathic, or spontaneous, erysipelas, so 
called, does not exist; every case of erysipelas is traumatic, in so far that 
by injury or disease the necessary infection-atrium must be created through 
which the streptococcus can reach the lymphatic vessels. In erysipelas with- 
out a tangible infection-atrium, infection occurs through a minute puncture 
or abrasion, which may, perhaps, never have attracted the patient's atten- 
tion, and which has become invisible at the time the disease is first noticed. 
Infection, however, may also take place through a mucous membrane, 
through which the microbes enter the tissues in the same manner and under 
the same conditions as when infection takes place through the skin. One 
of the severest cases of erysipelas that ever came under my observation com- 
menced in the pharynx, or tonsils, and, as the symptoms subsided here, a 
typical and severe facial erysipelas developed. As the patient was suffering 
at the same time from secondary syphilis, it is probable that the streptococcus 
of erysipelas entered the tissues through the secondary syphilitic lesions in 
the pharynx. In the tissues the streptococcus of erysipelas invades the 
lymphatic channels exclusively, and manifests here its specific pathogenic 
qualities. 

The erysipelatous inflammation is, in reality, a specific, progressive 
lymphangitis, the paralymphatic tissues becoming affected by contiguity. 
Within the lymphatic channels the microbe multiplies, and diffusion of the 
infection takes place in the course of the lymphatic vessels, but does not al- 
ways follow in the direction of the lymph-stream. The lymphatic vessels are 
often found crowded with the microbe, which is destroyed in a short time, 
as with the subsidence of the inflammation the microbe disappears. Accord- 
ing to Koch and Fehleisen, the microbe is always found most numerous in 
the portion of the skin corresponding to the border of the inflamed area. At 
this point the lymphatics frequently appear completely blocked by dense 
colonies of this microbe, so that no lymph-corpuscles can be seen among 
them. As the inflammation extends to the surrounding connective tissue, 
some of the microbes leave the lymphatics and enter the connective-tissue 
spaces, where they come in contact with the inflammatory exudation. Within 
the lymphatic vessels the streptococci are found between the lymph and col- 
orless blood-corpuscles; in the connective tissue they are found also within 
the protoplasm of leucocytes. 

Metschnikoff maintains, in opposition to most of the modern authors, 



418 



PRINCIPLES OF SURGERY 



that the arrest of the extension of the erysipelatous inflammation is accom- 
plished by phagocytosis. The accumulation of leucocytes in the inflamed 
tissues has, undoubtedly, a salutary effect in mechanically blocking the 
avenues through which infection takes place; but as most of the microbes 
are outside of, and not within, the leucocytes and lymph-corpuscles, it is dif- 




Fig. 156.— Section through Skin near the Margin of the Erysipelatous Zone. 1, 1, each 
a lymphatic vessel filled with streptococci in chains. X 700. {Koch.) 

ficult to conceive how limitation of the extension of the infection could be 
accomplished solely by phagoc}^tosis. The microbes have a very short ex- 
istence in the tissues; the inflammation which they initiate continues for 
some time after all microbes have disappeared. The toxins which the mi- 
crobes secrete produce protoplasmic alteration of the connective-tissue cells 
and the capillary blood-vessels, which prolong the inflammation beyond the 
period when the tissues are in a sterile condition. Others have claimed that 




Fig. 157.— Section of Skin in Erysipelas, v, v, section of two lymphatic vessels 
containing white corpuscles and chains of cocci; m, m, chain cocci; t, connective tis- 
sue; a, connective tissue and migrating cells. X 600. (After Comil and Babes.) 

self-limitation of erysipelas is due to destruction of the microbes by the high 
temperature which attends the disease. De Simone has recently shown that 
pure cultures of the streptococcus of erysipelas lose their power of reproduc- 
tion if they are exposed for two days consecutively to a temperature of 39.5° 
to 41° C. Clinical experience, however, has demonstrated conclusively that 



RELATION OF ERYSIPELAS TO PUERPERAL FEVER. 419 

erysipelas is not arrested in its course by a temperature of 10° C. or more. 
It appears that the streptococcus exhausts the soil of the nutrient material 

which it requires for its growth and reproduction in a short time. In the 
blood-vessels of the inflamed skin no streptococci can be found, bul that they 
occasionally enter the blood-vessels is sufficiently evident from the occur- 
rence of met astatic erysipelas and the direct transmission of erysipelas 
from mother to foetus by infection through the placental circulation. As 
the streptococcus of erysipelas produces its pathogenic effects in the lym- 
phatic vessels and diffuses itself through these channels in the tissues, it 
becomes obvious that in all cases infection takes place as soon as localiza- 
tion is effected in the superficial lymphatic structures, or in the spaces 
eontributary to them and in direct connection with an infection-atrium. 

RELATION OF ERYSIPELAS TO PUERPERAL FEVER. 

Obstetricians recognized the danger of exposing puerperal women to 
the infection which might emanate from erysipelatous patients long before 
the microbe of erysipelas was known. Since the discovery of the microbe 
by Fehleisen, this subject has attracted renewed attention, and positive 
knowledge has accumulated both from accurate clinical observation and from 
the fertile and more positive field of experimentation. Gusserow asserted, 
upon the basis of an extensive experience, that no direct etiological relations 
exist between the contagium of erysipelas and puerperal fever. He had 
under his care puerperal women suffering from erysipelas of the skin with- 
out any serious disturbances following in the genital tract. In 10 other 
cases, 1 of them occurring during an epidemic of puerperal fever, the ery- 
sipelas was observed as a complication of septic affections of the genital or- 
gans. Gusserow claims that in this case it cannot be claimed that erysipe- 
las could have caused the puerperal affection, as the latter preceded the 
former. But another point could be raised, as it might be claimed that the 
septic processes should be made answ r erable for the occurrence of erysipelas. 
This author has studied this subject also by way of experiment. A pure 
culture of the streptococcus erysipelatosus, which had been tested and found 
reliable in producing erysipelas by the usual methods of inoculation, was 
injected into the peritoneal cavity of 2 rabbits; in 2 others it was applied to 
an open wound of the abdomen, and in the last 2 animals it was injected into 
the subserous collective tissue of the peritoneum. In all of these animals 
no effect was produced, and no pathological changes were detected at the 
point of injection when the animals were killed, some time after the in- 
oculation. Gusserow looks upon the results of these experiments, if not as 
positive proof, nevertheless as strong evidence against the claim that ery- 
sipelas can cause puerperal sepsis. Winckel, an equally reliable and able 
observer, has come to entirely opposite conclusions. He cultivated from a 



420 PRINCIPLES OF SURGERY. 

parametritic abscess, which had developed after childbed, Fehleiserrs strep- 
tococcus. Injections of this culture into rabbits produced typical erysipelas. 
The same author also observed erysipelas following in a puerperal woman 
suffering from suppurative perimetritis, pleuritis, and metrolymphangitis. 
The patient died on the thirteenth day. The starting-point of the e^sipelas 
could be traced to an ulcer of the vulva. Blood taken from the right side 
of the heart soon after death was inoculated upon a solid nutrient medium, 
and produced a culture of the streptococcus of erysipelas. The same culture 
was obtained by inoculations with fluids taken from the peritoneal and 
pleural cavities, the uterus, kidneys, and the liver. In 3 cases a culture thus 
obtained was injected into the peritoneal cavity of rabbits, and no perito- 
nitis followed. In one experiment the injection produced suppurative peri- 
tonitis. Guinea-pigs proved less susceptible to infection than rabbits. In 
white mice the inoculations were invariably joroductive of a fatal disease. 
From the results of these experiments the author claims that the virus of 
erysipelas is one of the most virulent puerperal poisons, and believes that 
they prove the causal relations of erysipelas to puerperal sepsis. 

Doyen also found, both in mild and severe cases of puerperal fever, a 
streptococcus similar to the one described by Eosenbach and Fehleisen. He 
made some inoculations to determine the relationship between puerperal 
sepsis and erysipelas. The streptococcus found in the infected tissues of 
puerperal-fever patients caused erysipelas, and the streptococcus found in 
erysipelas developed puerperal fever. From his own observations and ex- 
periments the author arrived at the conclusion that the microbe of puerperal 
sepsis is the same as that of erysipelas. From a clinical and bacteriological 
stand-point it is evident that puerperal sepsis from infection with the strep- 
tococcus of erysipelas can only occur when the streptococcus is brought in 
contact with an absorbing surface in the genital tract; but when this takes 
place, and the microbes reach the enlarged kymphatic vessels of the puer- 
peral uterus, the most violent and fatal form of puerperal sepsis is almost 
certain to follow. 

RELATION OF ERYSIPELAS TO PHLEGMONOUS INFLAMMATION AND 

SUPPURATION. 

Some difference of opinion still exists, among bacteriologists, with re- 
gard to the question whether the streptococcus of erysipelas possesses py- 
ogenic properties. The majority of those who have studied this subject ex- 
perimentally do not consider the streptococcus of erysipelas as a pus-mi- 
crobe, and assert that when suppuration takes place in erysipelas it is the 
result of a secondary infection with pus-microbes, and, on this account, look 
upon phlegmonous inflammation as a complication, and not as a condition 
belonging to the erysipelatous process. Hajeck made careful investigations 



RELATION DO PHLEGMONOUS INFLAMMATION AND SUPPURATION. 421 

fco show thai the streptococcus o\' erysipelas is neither in form nor culture 
materially different from the streptococcus pyogenes, hut he showed, also, 
that in 51 cutaneous or subcutaneous inoculations with a pure culture of the 
streptococcus of erysipelas in rabbits the result was always a superficial mi- 
grating dermatitis which resembled to perfection erysipelas in man, while 
similar injections with the streptococcus of pus produced a more intense 
and deeply-seated inflammation, which in almost every instance terminated 
in suppuration. The difference in the action of the two microbes on the 
tissues plainly demonstrated their non-identity. Microscopical examination 
of the inflamed tissue showed a still more important difference as far as the 
localization and local diffusion of the microbes were concerned. The mi- 
crobe of erysipelas was always found with, the products of inflammation 
within the lymphatic vessels, and only exceptionally in the connective-tissue 
spaces, which anatomically are only a part of the lymphatic system. The 
pus streptococcus penetrates the tissues more deeply; it is not only found 
in the lymphatic vessels and connective-tissue spaces, ~but it migrates beyond 
the lymphatic channels and infects different kinds of tissue, thus giving rise 
to a more deeply seated and more intense inflammation. The streptococcus 
of erysipelas is found only exceptionally in the immediate vicinity of blood- 
vessels, while the microbe of pus can always be se&n arranged in radiate lines 
around vessels entering the adventitia, the muscular coat, and often even the 
lumen of the vessel. In man the same histological differences can be seen 
in the tissues the seat of erysipelatous and phlegmonous inflammation as in 
the artificial conditions in animals subjected to experiment, and the same 
pathological differences are also constantly found. The author asserts that 
Fehleisen was in error when he claimed that the formation of abscesses oc- 
curred independently of the erysipelatous infection. He affirms that, in 
rabbits inoculated with the virus of erysipelas, after the acute inflammation 
has subsided circumscribed small nodules which remain may suppurate, but 
suppuration never becomes diffuse; while after injection with cultures of 
the streptococcus pyogenes the inflammation assumes a phlegmonous type 
and the suppuration is always more diffuse. Hajeck maintains that under 
certain circumstances a circumscribed superficial suppuration can also take 
place in erysipelatous inflammation in man. When suppuration in a joint 
takes place, however, it is not caused by the erysipelatous infection, but is 
due to the presence of pus-microbes. Eiselsberg, Bonome, Bordini, Passet, 
and Simone are of the opinion that the streptococcus of erysipelas and the 
streptococcus of suppuration do not differ in their pathogenic effects. 

Smirnoff found in one case of erysipelas the specific microbe in the 
metacarpo-phalangeal joint of the left hand, which was the seat of the dis- 
ease. In the case of a man who had died of erysipelas, enormous colonies of 
the streptococcus were found in the right shoulder- and knee- joints. The 



422 PRINCIPLES OF SURGERY. 

synovial fluid injected into rabbits occasioned erysipelas migrans. Accord- 
ing to the recent researches of von Lingelsheini, the streptococcus pyogenes 
differs from the streptococcus erysipelatous in being pathogenic both for 
mice and rabbits, while the latter is pathogenic for rabbits only. 

Eheiner found Fehleisen's streptococcus in all cases of traumatic ery- 
sipelas which he examined, but was unable to find it in 2 cases of gangrenous 
erysipelas following typhus. In these cases he found bacilli which he be- 
lieved were identical with Klebs-Ebertlr s bacillus of typhus. At the pres- 
ent time the opinion of the identity of the microbes of pus and erysipelas is 
again gaining ground. Schonfeld found the same coccus in the lungs and 
especially in the dilated lymphatics of this organ in a patient who died from 
the effects of an attack of erysipelas complicated by fibrinous pneumonia. 
Mosny obtained a pure culture of the streptococcus of erysipelas from the 
inflamed lung of a servant who attended his master during an attack of 
facial erysipelas and who died the second day after an attack of pneumonia. 
Jordan, who is a firm believer in the non-specific nature of the microbe of 
erysipelas, made a careful clinical and bacteriological study of 2 cases of 
erysipelas in the clinic at Heidelberg. In the first case the disease started 
as a typical facial erysipelas and which was attended by phlegmonous in- 
flammation of the forehead and adipose tissue of the orbital regions, and was 
soon followed in rapid succession by metastatic periostitis of right fibula, 
erysipelas of skin of leg, migrating pneumonia of both lungs, dilatation of 
heart, recurring erysipelas of face. The patient finally recovered. From 
all of the lesions, local and distant, he cultivated the staphylococcus pyog- 
enes aureus. The nurse who attended this patient was taken with facial 
erysipelas on the third day, and from the serum obtained from a puncture 
near the erysipelatous zone he cultivated the same microbe. 

Kahlden, after a careful study of the recent literature on erysipelas 
and the difference in opinion on the pathogenic properties of the strepto- 
coccus erysipelatous, remarks that the subtility in the differences between 
the morphology and the cultures of the microbes of erysipelas and the strep- 
tococcus of suppuration is undoubtedly the reason why no uniformity of 
opinion exists in regard to their specific pathogenic effects, especially as to 
the possibility of Fehleisen's streptococcus producing suppuration. To this 
I might add that not every superficial diffuse inflammation of the skin is 
erysipelas, and not every abscess occurring during, or soon after, an attack 
of erysipelas should be considered as a product of the erysipelatous infection. 
The surgeon will do well to adhere to the teachings of Fehleisen, who is 
positive in his assertion that the streptococcus of erysipelas never produces 
suppuration, until more convincing proof shall have been furnished of the 
pathogenic identity of the streptococcus of erysipelas and the streptococcus 
of suppuration. 



SYMPTOMS AND DIAGNOSIS. 12:1 



SYMPTOMS and diagnosis. 

Erysipelas, like most of the acute infectious diseases, has no well- 
marked premonitory stage, the attack being sudden and followed by all the 
symptoms which usher in an acute febrile affection. The period of incuba- 
tion in man has been fixed at from fifteen to sixty-one hours by the inocula- 
tions which have been made to produce the disease artificially for therapeu- 
tic purposes. Inoculations prove successful if the skin is punctured with a 
needle the point of which had been dipped into a pure culture of the strep- 
tococcus. Such punctures have no visible lesion after a few hours: a fact 
which readily explains the disappearance of a visible infection-atrium at the 
time the disease appears, in cases of erysipelas developing without a demon- 
strable breach of continuity in the skin. Eoger records 597 personal ob- 
servations of erysipelas. Of this number, he was able to calculate with pre- 
cision the time of incubation in 41 cases. In 5 cases it was less than 18 
hours; in 5 more it ranged from 18 to 24 hours; the longest period was 
1 case in which it occupied 22 clays. However, in this case he admits the 
possibility of a later infection. 

In the adult the disease commences, almost without exception, with 
a chill which sometimes amounts to a severe rigor. Nausea and vomiting 
are often present during the first few hours. The chill is followed by a 
rise in the temperature, which in a few hours increases to 104° F. or more. 
The fever assumes a continuous type, and in uncomplicated cases the dif- 
ference between the morning and evening temperature is slight. Headache, 
thirst, and complete loss of appetite are constant and prominent symptoms. 
The pulse is at first full and bounding and seldom exceeds 100 beats per 
minute. In severe cases delirium is present almost from the beginning, and 
continues until the fever subsides. Almost simultaneously with the appear- 
ance of the general symptoms, the skin in the immediate vicinity of the 
infection-atrium shows evidences of the existence of a superficial inflam- 
mation. The patient complains of a sense of tightness in the part, which is 
accompanied by a burning and itching sensation. 

In traumatic erysipelas the wound presents no changes in its appear- 
ance; if suppuration is present the purulent discharge becomes somewhat 
diminished in quantity and the pus is rendered more serous. The skin 
around the seat of infection is firmer to the touch, and, if the erysipelas has 
started from a wound, infection has occurred from a certain portion of the 
wound, while the remainder shows no evidences which point to erysipelatous 
inflammation. The skin which is involved by the erysipelatous inflammation 
presents, almost from the beginning, a characteristic rose or crimson color. 
"With the appearance of the typical discoloration the inflammatory exuda- 
tion has reached its height. The color disappears under pressure, but upon 



424 PRINCIPLES OF SURGERY. 

the removal of the pressure no depression is left, showing that little or no 
oedema is present. The induration of the skin is most marked at the border 
of the erysipelatous zone, and disappears with the absorption of the inflam- 
matory product and the return of the natural color of the skin. The mar- 
gin of the zone is abrupt and distinct on the side of the healthy skin. The 
border of the erysipelatous zone is not straight, but irregular, and often 
fan-like projections can be seen and felt which project into the healthy skin, 
and, when present, they are characteristic, almost pathognomonic, of this form 
of dermatitis. The degree of swelling varies according to the intensity of the 
infection and the anatomical structure of the part involved. 

If the infection is intense and parts are implicated which are abun- 
dantly supplied with loose connective tissue, the swelling is greater than in 
cases where the infection is mild or the skin is stretched over firm, resisting 
parts. In facial erysipelas, for instance, the swelling is much greater around 
the orbits than in the scalp, because in the former locality the loose, cellu- 
lar, connective tissue underneath the skin becomes swollen and cedematous 
from the escape into it of the inflammatory transudation. 

The specific inflammation, starting from the point of infection, spreads 
continuously and uninterruptedly along the course of the superficial lym- 
phatics, but is not limited to the direction of the lymph-current. The intra- 
lymphatic diffusion of the streptococcus is not a passive, but an active, proc- 
ess. As this microbe is non-motile, its transportation in a direction opposite 
to the lymph-stream can only occur by its reproduction. The lymph-current 
in most, if not all, ~of the inflamed lymphatic vessels is temporarily arrested by 
the blocking of the interior of the lymphatic vessels with colonies -of the strepto- 
coccus and the accumulation of lymph-corpuscles; consequently the colonies 
become fixed points from which new tissues are infected by their increase in 
size in all directions, muing to rapid reproduction of the microbe. The fever 
continues until the infection comes to a stand-still. The intensity of the 
subjective s}Toptoms does not always correspond with the temperature, as 
patients may feel quite well when the temperature registers 104° to 105° 
F., while others show evidences of a serious disturbance with a much lower 
temperature. Large bullae usually result from confluence of a number of 
vesicles. The contents of these blisters are first serous, but suppuration may 
follow later from the entrance of pus-microbes. Bullae with hemorrhagic 
contents denote a grave attack. 

The duration of erysipelas is extremely variable. Genuine e^sipelas 
may run a typical course and terminate in recovery in two days, or the dis- 
ease may extend over a period of two weeks or more. The extent of surface 
successively invaded determines its duration. If it start from a wound of 
the hand it may extend along the forearm and arm to the shoulder, from 
here along the back to one or both of the lower extremities, and before such 



CLINICAL FORMS OF ERYSIPELAS. 425 

I large territory of skin lias passed through all the stages of the disease more 
i han four weeks may elapse. As soon as the disease ceases to migrate the 
general symptoms subside, and within a few days the skin returns to its nor- 
mal condition and the patient recovers his usual health in a remarkably 
short time: a fact which tends to prove that erysipelas, in its uncomplicated 
form, does not impair the function of any of the internal organs to any 
considerable extent. Exfoliation of the skin is a usual occurrence. In the 
differential diagnosis we have to consider lymphangitis, erythema, phleg- 
monous inflammation, and thrombophlebitis. In lymphangitis from other 
causes than the streptococcus of erysipelas the inflammation follows larger 
lymphatic channels, which appear as red lines, and seldom, if ever, is the 
skin proper involved in the inflammatory process, while erysipelas is a com- 
bination of lymphangitis with dermatitis. Erythema appears as circum- 
scribed points of inflammation in the skin with healthy tissue between, 
while, on the other hand, erysipelas shows no such interruptions, the inflam- 
mation being a continuous, uninterrupted process followed by speedy repair. 
Phlegmonous inflammation is accompanied by inflammation of the skin, 
which in its external appearances closely resembles erysipelas; but the dif- 
ferential diagnosis rests on the location of the primary inflammation, which 
is always the superficial lymphatics of the skin in erysipelas and the sub- 
cutaneous tissue in phlegmonous inflammation. In phlegmonous inflam- 
mation there is no abrupt border of the redness of the skin as in erysipelas. 
The redness of the skin in the former affection gradually shades into the 
usual color of the skin. In phlegmonous inflammation the deep-seated in- 
flammatory exudation is the primary pathological condition, and the lym- 
phangitis follows as a secondary result, while in erysipelas the primary spe- 
cific lymphangitis and dermatitis are primary conditions; and if the subcu- 
taneous tissue become involved later on it must be regarded as a complica- 
tion, and not as an integral part of the disease. Patients suffering from 
erysipelas complain of a smarting, burning, or itching sensation in the af- 
fected skin; phlegmonous inflammation is attended by severe pain, which is 
of a throbbing character. Thrombophlebitis, starting from a chronic ulcer 
of the leg, has often been mistaken for erysipelas, not only by laymen, but 
also by physicians. Thrombophlebitis is often attended by inflammation of 
the tissues around the inflamed vein and of the superimposed skin (peri- 
phlebitis), but the inflammation follows in the course of the vein, and not 
in the course of lymphatics; at the same time the vein can be felt as a solid, 
tender cord. 

CLIXICAL FORMS OF ERYSIPELAS. 

The clinical forms of erysipelas are identical in so far that they are all 
caused by the same microbe, and that the disease primarily consists of a 



426 PRINCIPLES OF SURGERY. 

specific lymphangitis and dermatitis; but they vary greatly, according to the 
location and structure of the part affected, the intensity of the infection, 
and the existence of complications. 

Erysipelas Erythematosum. — This is the mildest form of erysipelas. It 
is described as erythematic because the affected skin shows but little swell- 
ing, and the affection appears more as an efflorescence than an inflammation. 
No bullae form, and only slight exfoliation takes place during convalescence. 

Erysipelas Bnllosum. — In this form the inflammation of the skin is 
more intense and the swelling more marked, in consequence of which blisters 
or bullae form underneath the cuticle. The pathological condition resem- 
bles a burn in the second degree. Eemoval of the cuticle leaves the papil- 
lary layer of the skin exposed. The bullae often become the seat 'of second- 
ary infection with pus-microbes, which transform the serous contents into 
pus. From such superficial foci of suppurative inflammation may develop 
what has been termed 

Phlegmonous Erysipelas. — As we are not in possession of conclusive 
proof that the streptococcus of erysipelas possesses pyogenic properties, we 
can only explain the occurrence of phlegmonous inflammation of the tissues 
underneath the skin affected by erysipelatous inflammation by taking it for 
granted that the deep-seated phlegmonous inflammation is caused not only 
by the streptococcus of erysipelas, but by the accidental entrance into the 
tissues of microbes of suppuration. As soon as secondary infection with 
pus-microbes takes place the clinical picture of erysipelas is overshadowed 
or obscured by the suppurative inflammation. The typical general and local 
symptoms which characterize the erysipelatous inflammation give way to 
symptoms which indicate the existence of a diffuse suppurative inflamma- 
tion. The temperature shows greater remissions, and the pulse becomes 
more rapid and feeble. The tongue is often red and dry, while all of the 
remaining symptoms point to intoxication from absorption of toxins pro- 
duced in the tissues by the pus-microbes. The swelling of the part affected 
is no longer limited to exudation into the substance of the skin, but affects 
main]y the deep-seated tissues. 

We have reason to believe that in most, if not in all, cases of phleg- 
monous erysipelas the secondary infection with pus-microbes takes place 
from a superficial suppurating focus as from a suppurating bulla, and that 
the microbes from here invade the subcutaneous connective tissue. The 
phlegmonous inflammation spreads with great rapidity, so that in a few 
days the skin of an entire extremity may become undermined with pus, the 
patient, in the meantime, having complained but little of pain. Such an ex- 
tremity on palpation imparts the sensation of a partially filled diffuse ab- 
scess-cavity. The external appearances furnish, often, no reliable indica- 
tions of the extent of the deep-seated destruction. If incisions are made at 



( LINICAL FORMS OF ERYSIPEL LS. Wi 

this time a Large quantity of pus escapes, mixed with Bhreds of necrosed con- 
nective tissue, and examination reveals extensive destruction of the subcu- 
taneous connective tissue and intermuscular septa. Phlegmonous inflam- 
mation, as a rule, does ooi attack tissues the seat of an erysipelatous inflam- 
mation, but the tissues weakened by this disease and infected with pus-mi- 
crobes. A sudden increase in the temperature of patients suffering from 
erysipelas is often the first symptom which announces this complication, and 
such an occurrence should admonish the attendant to detect it early in order 
to -ubject it to timely and efficient treatment. 

Erysipelas Gangrenosum. — This is an exceedingly grave form of ery- 
sipelas. Most of the authors are of the opinion that if the streptococcus of 
erysipelas multiplies with sufficient rapidity, in the interior of the lym- 
phatic vessels and the connective-tissue spaces, so as to completely block 
these channels by its growth, a sufficient amount of toxins is produced to 
cause necrosis of the tissues, and under such circumstances the erysipela- 
tous inflammation terminates in gangrene of the skin. This gangrene may 
take in circumscribed multiple patches, so that after separation and elimi- 
nation of the dead tissue the skin present a cribriform appearance or it 
may involve a large district of the skin, and then give rise to extensive loss 
of this structure in case the patient survives the disease. As the gangrene 
often commences in the portion of skin covered by bullae, it still remains an 
open question whether it results from the action of the streptococcus of 
erysipelas or whether it is the result of a secondary infection with pus- 
microbes. Isolated patches of gangrene of the skin are met with in many 
cases that terminate in recovery, but extensive gangrene of the skin is al- 
ways a serious complication, as it may result in death from septicaemia, or, 
if life is not destroyed, it at least greatly protracts the recovery, and often 
calls for a tedious treatment to restore the lost tissue by skin-grafting. 

Erysipelas Metastaticum. — By metastatic erysipelas is meant the oc- 
currence of an erysipelatous inflammation in an organ or a part where the 
process developed separately from the primary field of infection. If, for 
instance, erysipelas should appear in an extremity opposite to the one pri- 
marily affected, without extension of the disease across the skin of the trunk, 
it would furnish a good example of what is meant by metastatic erysipelas. 
Again, if, during an attack of erysipelas of one of the extremities, the patient 
should be attacked with symptoms of meningitis, and at the necropsy the 
streptococcus of erysipelas could be demonstrated in the inflamed envelopes 
of the brain, this would furnish another illustration of metastatic erysipelas. 
Two possibilities present themselves in explaining the occurrence of meta- 
static erysipelas. In the first place, colonies of the streptococcus in an active 
condition might reach a part distant from the erysipelatous inflammation 
with the lymph-current, and, meeting with favorable conditions, might es- 



428 PRINCIPLES OF SURGERY. 

tablish an additional focus of erysipelatous inflammation, which, of course, 
would have to be necessarily in a part between the primary field of infection 
and the termination of the lymphatic vessels leading from the infected dis- 
trict. If no such connection can be established, then the metastatic process 
results from the entrance of streptococci in an active condition into the cir- 
culation and their localization in distant parts or organs by mural implanta- 
tion upon the walls of capillary vessels prepared for their localization and 
reproduction. In most instances metastatic erysipelas is of such an embolic 
origin. 

The occurrence of metastatic erysipelas of the skin or exposed mucous 
membrane could also be satisfactorily accounted for by the microbes enter- 
ing the tissues from without through a new and distant point of entrance, 
and in such a case it would not be in the form of a metastasis, but the result 
of a new inoculation in- a different part of the body. 

Erysipelas Migrans. — Migration of the inflammatory process is one of 
the characteristic clinical features of erysipelas. In ordinary cases migration 
is limited to the anatomical region affected. In cases of facial erysipelas 
the disease seldom spreads beyond the scalp, and in erysipelas of the extremi- 
ties the disease usually subsides after it has extended over an extremity. 
Migrating erysipelas is that form of the disease where the erysipelatous in- 
flammation extends from place to place, and from limb to limb. I have 
seen this form most frequently in infants, starting from the umbilicus or 
the external genital organs. I have seen it start from these points, ascend 
in an upward direction along the anterior aspect of the bod}^, and, after 
reaching both shoulders, spread to the upper extremities, later to descend 
down the back, and finally terminate in the toes, after traveling nearly over 
the whole surface of the body. Erysipelas of the extremities or trunk never 
extends to the face or scalp, while, in exceptional cases, erysipelas of the 
face assumes the migrating form. Migrating erysipelas is usually attended 
by only moderate swelling and slight constitutional disturbances. One 
peculiarity of this form of erysipelas is that the same regions may become 
involved a second time. 

Erysipelas Facialis. — This is the so-called spontaneous or idiopathic 
form of erysipelas, as in most cases even close inspection does not reveal the 
existence of an infection-atrium. The disease usually commences in one 
of the alas, or at the root of the nose: localities where minute skin lesions 
are frequently produced, and localities which, more than any other part of 
the face, are exposed to infection by contact. As far as its extension is con- 
cerned, facial erysipelas pursues the most typical course. The inflammation 
spreads toward the cheek and orbit on the side first affected, and then creeps 
across the bridge of the nose to the opposite side, to follow a similar course 
here. About the second or third day it reaches the forehead, and from here 



PROGNOSIS. 429 

and the outer margins o( the orbits it invades the scalp, to terminate, usu- 
ally about the end of a week, at the nape of the neck. The chin and ante- 
rior aspect of the neck never become affected in facial erysipelas. Facial 
erysipelas is attended by considerable swelling, the eyes being often com- 
pletely closed by the oedematous lids. Bullae bum frequently about the cen- 
tre of the cheeks and the forehead. One of the dangers of facial erysipelas 
sists in the direct extension of the erysipelatous inflammation from the 
skin along the blood-vessels to the meninges of the brain. The meningitis 
under these circumstances is not a metastatic process, but the result of a 
direct extension of the inflammation from the skin to the meninges, along 
structures which connect them through the intervening skull. Patients who 
have suffered from facial erysipelas are not protected against subsequent at- 
tacks; in fact, experience has shown that they are more prone to infection 
in the future than persons who have never suffered from this disease. If 
the bulla? suppurate, there is always danger arising from suppurative throm- 
bophlebitis, suppurative leptomeningitis, and suppurative encephalitis: fatal 
complications plainly attributable to secondary infection with pus-microbes. 
Traumatic Erysipelas. — TTe have seen that, in the strict sense of the 
word, all cases of erysipelas are traumatic in their origin, in so far that 
infection never takes place through the intact skin or a mucous membrane; 
consequently, the disease never occurs without an infection-atrium, which 
may be a wound or a lesion of the surface through which the streptococcus 
gains entrance into the lymphatic channels. The expression "traumatic ery- 
sipelas" is still retained for the purpose of designating erysipelas as one of 
the numerous forms of wound complications. If a recent wound is infected 
with the microbes of erysipelas the disease develops within fifteen to sixty- 
one hours after the accident or operation. The disease may occur in conse- 
quence of later infection at any time before cicatrization is completed, as 
granulations furnish no absolute protection against infection. I have seen 
the disease originate more frequently in granulating than in recent wounds: 
a strong argument in support of the advice that full aseptic precautions 
should not be relinquished until the healing process is completed, if the patient 
is to be protected against an attach of erysipelas. Another important fact 
should always be remembered: that small wounds are more frequently at- 
tacked by erysipelas than large wounds, because the latter receive more careful 
attention, and are, as a rule, subjected to more rigid aseptic treatment. 

PROGNOSIS. 

Simple uncomplicated erysipelas is not a fatal disease unless it attacks 
infants or persons debilitated by age or antecedent diseases. Death is caused 
more frequently by complications. The most common fatal complications 
are suppurative inflammation at the seat of erysipelatous inflammation, or 



430 PRINCIPLES OF SURGERY. 

metastatic suppuration in distant parts or organs, resulting from secondary 
infection with pus-microbes, or, finally, extension of the erysipelatous in- 
flammation to important organs, as the brain or its envelopes, in cases of 
facial erysipelas, or the occurrence of metastatic erysipelas in vital organs 
from embolic processes. The prognosis is, therefore, based largely upon the 
absence or presence of complications, which must be carefully sought for in 
all cases where general or local symptoms point to their existence. The 
temperature, pulse, and condition of nervous and digestive organs furnish 
important and valuable prognostic indications. 

TREATMENT. 

The number of specifics which at different times have been recom- 
mended in the local and general treatment of erysipelas must throw doubt 
upon the efficacy of any local applications or internal remedies in arresting 
the further progress of erysipelas. At the same time it must not be for- 
gotten that uncomplicated erysipelas is a disease which tends to spontane- 
ous recovery, and seldom proves fatal, even if it is allowed to pursue its own 
course, unaided by any local application or internal medication. The ery- 
sipelatous inflammation is of short duration, and passes through its different 
stages uninfluenced by local or general treatment. Since its microbic origin 
has been suspected different methods of treatment have been recommended 
to arrest the further progress of the disease by destroying or rendering inert 
the primary cause. Hueter aimed at the destruction of the specific microbe 
by injecting, at different points at the border of the erysipelatous zone, 5 to 
6 cubic centimetres of 3-per-cent. solution of carbolic acid. This method of 
treatment in the hands of others has been followed, almost without excep- 
tion, by negative results. It is possible that subcutaneous injections of a 
l-to-1000 solution of corrosive sublimate in non-toxic doses would yield 
better results. The continued application of cold, even of an ice-bag, has 
been found useless in arresting the disease. As it has been found that a 
temperature of over 40° C. continued for two days has at least an inhibitory 
effect on the growth of the streptococcus of erysipelas in artificial nutrient 
media, it would appear rational to resort to hot antiseptic compresses in the 
local treatment of erysipelas. If the area involved is limited, a compress, 
saturated with a weak hot solution of corrosive sublimate or carbolic acid, 
would answer a most admirable purpose. If a large surface is affected, some 
of the weaker germicidal solutions could be used in the same manner. 
Moisture and heat relieve also the burning, smarting sensation more 
promptly and efficiently than the different filthy oils and salves which have 
been employed. Application of tincture of iodine, muriated tincture of 
iron, and solutions of nitrate of silver are worse than useless, because thev 
destroy the skin, which should be carefully preserved in order to protect 



TREATMENT. 431 

the patient against secondary infection with pus-microbes. One of the best 
local applications is alcohol, either pure or slightly diluted. A compress well 
saturated with alcohol is applied ever the erysipelatous area and evaporation 
is prevented by applying over it gutta-percha or some other impermeable 
cover, ami the whole retained by a gauze bandage. 

Kraske recommended multiple minute incisions or, rather, scarifica- 
tions in the skin, at the peripheral zone of the erysipelatous inflammation, 
for the purpose of preventing farther extension of the disease. If the skin 
is first rendered aseptic, and subsequent secondary infection is guarded 
against by the application of a reliable antiseptic, this treatment may prove 
valuable in modifying the progress of the disease. After scarification a hot, 
moist, sublimated compress should be applied, to be immediately replaced by 
another when removed. The external use of ichthyol, so highly recom- 
mended, by Xussbaum, has proved, useless in my hands, both in relieving 
suffering and in preventing the extension of the disease. 

St. Klein appears to have obtained better results. He has treated 31 
cases of erysipelas with ichthyol applied externally, with excellent results. 
In his experience the disease seldom resisted this treatment for more than 
three or four days. He uses a preparation composed of equal parts of 
ichthyol and vaselin, which is applied tw T o or three times over the parts 
affected. Before the first application is made the skin is thoroughly 
cleansed with warm water and soap. After the ointment is rubbed in 
gently the surface is covered with a compress saturated with a solution, 
of salicylic acid and over this a thick layer of cotton. Benoy claims that 
he has been successful in aborting erysipelas in about 60 per cent, of his 
cases by local applications of ichthyol and traumaticin. 

Wolfler has called attention to the value of the mechanical treatment 
of erysipelas. He has published 18 additional cases of erysipelas treated 
by pressure made with strong adhesive plaster. After the plaster is applied 
the disease extends into the compressed parts of the skin, w r hich sw T ell con- 
siderably and remain swollen for several days, and then both the swelling 
and the fever diminish. He recommends that by w T ay of precaution a 
second line should be commenced several centimetres distant from the 
first. The part must be carefully inspected once or twice daily in order 
to detect any loosening of the plaster. Occasionally the erysipelatous in- 
flammation extends in diminished intensity for a short distance beyond 
the first line of plaster, but this does not last long. This method of treat- 
ment is at least harmless, and if future experience should prove, as it 
probably will, that it will not succeed in arresting the local extension of 
the disease, it will at least provide an efficient protection for the inflamed 
skin. 

Phlegmonous inflammation and metastatic suppuration should be pre- 



432 PRINCIPLES OF SURGERY. 

vented, as far as possible, by the employment of such measures as will 
guard against the formation of suppurating foci in the inflamed skin. 
Bullae should be evacuated as soon as they form by puncturing with an 
aseptic needle, carefully preserving the cuticle as a protection against 
the entrance of pyogenic microbes. Unaltered air should not reach the 
inflamed skin, and for this purpose it should be covered either with an 
antiseptic, moist compress, or a thick layer of antiseptic cotton. The skin 
is disinfected in advance of the extension of the disease, and is subse- 
quently protected against additional infection by applying a hot, moist 
antiseptic compress, or by covering it with antiseptic absorbent cotton. 
If suppuration take place in the interior of bullae the cuticle should be 
removed, after which the surface is carefully disinfected by irrigation 
with a germicidal solution, followed by an application of a 10-per-cent. 
solution of chloride of zinc, and further infection prevented by an anti- 
septic dressing. If phlegmonous inflammation develop in spite of these 
prophylactic measures, early and free incisions are made, free drainage 
established, and a subsequent treatment followed out appropriate for 
phlegmonous inflammation not complicated by erysipelas. Gangrene of 
the skin is to be treated by applying a hot antiseptic compress until the 
dead tissue is eliminated, when the defect is replaced by skin-grafting. 
Internal medication has even been less satisfactory than the local meas- 
ures in the treatment of erysipelas. During the febrile stage the admin- 
istration of the tincture of ferric chloride and the mineral acids does more 
harm than good. If the temperature is high, a daily antipyretic dose of 
quinine is indicated, and exerts a favorable influence upon the local process 
and the general condition of the patient. If the patient is restless a full 
dose of Dover's powder should be given at bed-time. Symptoms of pros- 
tration are met early by the use of a substantial wine or some other 
alcoholic stimulant. 

Symptoms of collapse are treated by administering internally 1 1 / 2 
grains of camphor every hour, or the same amount of the drug is dis- 
solved in oil of sweet almonds and injected subcutaneously every half- 
hour or hour until symptoms of intoxication, delirium, and reduction of 
the pulse to 50 or 55 beats per minute are produced. The camphor treat- 
ment in grave cases of erysipelas was introduced by Pirogoff, and has 
yielded excellent results when the threatening symptoms point to an 
enfeebled heart. 

This is the proper place to mention the antistreptococcic serum of 
Marmorek as a therapeutic agent in the treatment of streptococcic in- 
fection. This serum has received a fair trial since 1895, and the general 
experience has been very unfavorable indeed, including Marmorek's statis- 
tics. A committee appointed by the American Gynaecological Society to 



ERYSIPELOID. * 433 

investigate its merits reported adversely. Parascandolo has investigated 
the relation of the streptococcus pyogenes to the streptococcus of erysipe- 
las. He finds that the serum el' an animal immunized to one of these or- 
ganisms prevents a growth of the culture of the same organism and saves 
animals that have been injected with such cultures; but neither organism 
has the same protective power against the other; so that the author be- 
lieves that the organisms are different and that the treatment of erysipelas 
by antistreptococcic serum must be prepared from the streptococcus of 
erysipelas. He has found the best method of immunization is by the use 
of the toxins, and not by the employment of virulent cultures. Serum- 
therapy in the treatment of streptococcic infection — pyogenic and erysipel- 
atous — at the present time is in a very unsettled and unsatisfactory state, 
and it is very doubtful if much can be expected from this source in the 
future. 

EETSIPELOID. 

A new form of infective dermatitis, which in many respects resembles 
erysipelas, was described by Eosenbach in 1883 under the name of "ery- 
sipeloid." It attacks usually the fingers and exposed portion of the hand, 
and is most frequently met with in persons who handle game or dead ani- 
mals, as cooks, butchers, fish-dealers, and tanners. The affection starts 
from some minute abrasion of the skin as a bluish-red infiltration, which 
slowly advances in an upward direction. The inflamed parts are the seat 
of a burning, smarting sensation. While the skin at the point of infec- 
tion returns to its natural condition and color, the zone of infiltration 
becomes larger, as it continues to spread until the disease appears to ex- 
haust itself in the course of from one to three weeks. The infectious 
material which produces this disease is contained in decomposing animal 
substances. Infection may occur in any abraded part of the body which 
comes in contact with material containing the virus. The temperature 
remains normal, and the general health is not affected. The inflammation 
travels very slowly, so that if infection take place in the tip of a finger 
it reaches the metacarpo-phalangeal joint in about eight days, and during 
the second week it spreads over the back of the hand, from where an ad- 
jacent finger may become affected, the extension then taking a direction 
opposite to the lymph-current. Eepeated experiments to obtain a pure 
culture of the microbe failed, until in November, 1886, the author suc- 
ceeded in cultivating it upon gelatin from a case in which the disease could 
be traced to infection from old cheese. 

Eosenbach injected a pure culture under the skin of his own arm 
at three different points. After forty-eight hours he experienced a smart- 
ing, burning sensation at the points of injection; at the same time a 



434 PRINCIPLES OF SURGERY. 

circumscribed redness appeared around each puncture, which soon became 
confluent. On the fifth day each puncture was surrounded by a zone of 
inflammation the size of a silver dollar, somewhat elevated above the 
niveau of the surrounding skin. While the centre of this red patch be- 
came pale, the zone of inflammation continued to enlarge. In the in- 
flamed skin the capillary vessels could be seen dilated: a condition of the 
circulation which imparted to the tissues an arterial hue with a slight 
tinge of brown, while inside of the zone the color was a livid brown. In 
the skin which had returned to its normal pale color slight suggillations 
appeared, as though some of the red blood-corpuscles in the tissues had 
been destroyed during the progress of the disease. The inflammation 
appeared to have completely subsided on the eighth day, when the smart- 
ing sensation returned, and a new zone appeared around the old one. On 
the tenth day the area measured in its transverse diameter 24 centimetres, 
and in the parallel direction of the arm 18 centimetres. 

After this the affection disappeared permanently. During all this 
time the general health remained unimpaired, and the temperature varied 
from 36.8° to 37.2° C. A microscopical examination of the pure culture 
showed that it was composed of swarms and heaps of irregular, round, and 
elongated bodies somewhat larger in size than the staphylococcus. The 
author first believed that these bodies were cocci, but later he saw a net- 
work of intertwining threads, and decided that they were thread-forming 
microbes. In old cultures the threads were very abundant, and arranged 
in every possible way and direction. These threads appeared as though 
branches were given off, but on closer examination it could be seen that 
no organic connection existed between them. Terminal spores at the tips 
of the threads were numerous and could not be stained. Neither the 
microbes nor the threads manifested motile power in the culture, or when 
suspended in water; a gelatin culture became visible on the fourth day 
as a delicate cloud, which increased in size very slowly at a temperature 
of 20° C. The older cultures change into a brownish-gray color, and then 
resemble the culture of the bacillus of septicaemia in mice. In cultures 
4 months old the growth was not entirely suspended. The author, as yet, 
has not given a name to this microbe, but believes, on botanical grounds, 
that it belongs to the "cladothrix" variety of microorganisms. He wished 
to ascertain the action of this microbe on lupus, but in several cases in 
which it was tried the inoculations failed. Erysipeloid is a harmless form 
of infection, and subsides spontaneously in the course of two or three 
weeks. I have seen a number of cases in persons handling fish and game, 
where the affection started in one of the fingers, extended slowly as far 
as the dorsum of the hand, and then gradually invaded an adjacent finger 
and the back of the hand as far as the wrist. In the cases that have come 



ERYSIPELOID. 435 



under my observation the inflammation never extended beyond the wrist. 
The disease is self-limited, and its local extension is not arrested by any 
topical applications. 



CHAPTEE XVII. 

Tetanus. 

The wound-infective diseases in which the microbes or their toxins 
act upon the central nervous system are represented by tetanus and hydro- 
phobia. The specific microbes which are the cause of these diseases pro- 
duce no gross pathological changes in the brain or spinal cord, but the 
minute tissue-changes cause a central irritation, which is manifested by 
spasm of certain definite muscular groups. Tetanus is an infective disease 
in which the specific microbic cause exerts its pathogenic action on the 
central nervous system, and which is clinically characterized by spasm and 
rigidity of definite muscular groups. 

BACTERIOLOGICAL STUDIES. 

The classification of tetanus with the infectious diseases is of recent 
date, but the infectious nature of the disease was well known and estab- 
lished before the discovery of the bacillus tetani. In 1859 Betoli related 
the case of a bull that died of tetanus after castration. Several slaves 
ate some of the flesh of the dead animal, and of these 3 were (in a few 
days) seized with tetanus and 2 of them died. He adds, further, that 
in Brazil, where this occurred, the flesh of animals dead of tetanus is 
generally regarded as capable of transmitting the disease. In 1870 Anger 
reported a case in which a horse had spontaneous tetanus, after which 
3 puppies which had been in the same stable were also affected. Larger, 
in 1853, saw a woman who had a fall while cleaning a farm-yard, causing 
a slight wound of the elbow. Four weeks later she was seized with tetanus, 
and on investigation it was found that a horse affected with that disease 
had been in a stable opening into the yard where she fell. He also men- 
tions another circumstance which strongly points to the infectious nature 
of tetanus. In a small village, where tetanus was previously unknown, 
5 cases appeared in eighteen months under quite different climatic con- 
ditions. Of these, 1 had been taken to a hospital, after which 2 others in 
the same ward became affected with the disease. In 1884 Carle and Eat- 
tone produced the disease artificially in animals by inoculations with pus 
from tetanic patients. Nearly at the same time the real microbic cause 
of tetanus was discovered by Mcolaier and Eosenbach. Nicolaier showed 
the exogenous origin of the disease by finding a bacillus in earth which 
produced tetanus in animals when injected into the tissues. Eosenbach 
found the same bacillus in the pus of a patient suffering from traumatic 
tetanus. The identity of the bacillus of tetanus with Mcolaier's bacillus- 
of-earth tetanus was demonstrated in Koch's laboratory, April 10, 1887. 

(436) 



BACTERIOLOGICAL ST1 D] ES. 



437 



Bacillus Tetani. — Eosenbach describes the bacillus as an anaerobic 
microorganism which presents a bristly appearance, with a spore at one 
of its extremities which gives it the resemblance to a pin or drum-stick. 

According to Kitasato, the bacilli produce spores in thirty hours in 
cultures kept at a temperature of the body. They possess great resistance 
to heat, as they have been found active after an exposure of one hour to 
80° C. of moist heat, but they are destroyed by placing them in a steril- 
izer heated to 100° C. for five minutes. The bacillus has been found in 
different kinds of surface soil and in street-dust. In man it has been 
found in tetanic patients in the wound-secretions, in the nerves leading 
from the seat of infection, and in the spinal cord. 




Fig. 158. 



-Tetanus Bacilli. Spore-bearing rods from an agar culture. Mounted prepa- 
rations, stained with fuchsin. X 1000. (Frankel-Pfeiffer.) 



Cultivation. — Eosenbach found it impossible to obtain a pure culture; 
although he resorted to fractional cultivation, it was found that the last 
culture was still contaminated by one or more additional microbes. 
Fliigge claimed to have obtained a pure cultivation by heating for five 
minutes the mixed culture to 100° C, but after this procedure the bacillus 
was incapable of further propagation. After many trials it was found 
that sterilized solid blood-serum was the best soil for the propagation of 
the bacillus outside of the body. Both Xicolaier and Eosenbach observed 
the anaerobic nature of the bacillus, as it was found impossible to obtain 
a culture by streak inoculations, or in any other manner by which oxygen 
could not be excluded. The culture appeared slowly, as a delicate, 
whitish-gray film, in the track of the stab inoculation, below the surface 
of the culture-substance. By a long series of cultures Eosenbach finally 



438 



PRINCIPLES OF SURGERY. 



succeeded in eliminating all other microbes with the exception of a bacil- 
lus of putrefaction. The growth of the bacillus takes place most readily 
at an equable temperature of 37° C. (98.6° F.), and becomes first visible 
about the third day in the depths of the culture-media. Kitasato finally 
succeeded in obtaining a pure culture of the bacillus of tetanus from pus 
taken from a patient suffering from this disease. As the bacillus will 
only grow where atmospheric air can be excluded, he exposed his cultures 



to hydrogen-gas with complete exclusion of 



Mixed cultures, 









Fig. 159.— Culture of Bacillus Tetani in Nutrient Gelatin. (Kitasato.) 

which had been kept for several days in the incubator, were then exposed 
for half an hour to a temperature of 80° C. Further growth was then 
obtained upon plate cultures in closed glass vessels filled with hydro- 
gen-gas. By heating the mixed culture to 80° C. he destroyed all microbes 
with the exception of the bacillus of tetanus, which, later, was cultivated 
upon solid nutrient media in an atmosphere of hydrogen-gas. At a tem- 
perature of 18° to 20° C. a visible culture appeared at the end of a week. 
If the temperature was increased to blood-heat the bacilli and spores de- 
veloped more rapidly. 



BACTERIOLOGICAL STUDIES. 439 

Inoculation Experiments. — Nlcolaier produced tetanus in rabbits and 
mice; experimentally^ by inoculations with differeni kinds of surface soil. 
Out of 1-AO experiments in 69 a disease was produced identical with tela mis 
in man. In the pus, at the point of inoculation, bacilli and micrococci 
were constanly found. Among the bacilli one form was constantly pres- 
ent; this bacillus resembled in appearance and culture the bacillus of 
septicaemia in mice, but was more slender. This bacillus was found in 
isolated places in the connective tissue, but could not be found in the 
muscles, nerves, and blood. Earth sterilized by exposing it to a high tem- 
perature for an hour proved harmless, showing conclusively that the con- 
tagium of tetanus had been destroyed. Inoculations with pus taken from 
tetanic animals were most successful. Inoculations with mixed cultures 
grown in solidified blood-serum yielded positive results. 

Eosenbach made his experiments with mixed cultures grown from 
pus taken from the line of demarcation of a case of frost gangrene in 
a patient who had died of tetanus. The inoculations proved successful. 
Bonome reports the case of a man suffering from paraplegia, the result 
of disease of the spine in the dorsal region, complicated by an extensive 
sacral decubitus, the seat of phlegmonous inflammation, who was sud- 
denly attacked by tetanus, which proved fatal in two days. One hour 
after death a small portion of the infiltrated tissue around the gangre- 
nous part was removed, and after reducing it to a fine pulp by tritura- 
tion he injected it under the skin of a rabbit. Twenty- two hours after 
inoculation the animal died with well-marked symptoms of tetanus. The 
products of inflammation from the point of injection thrown into the sub- 
cutaneous tissue of other animals produced the disease, while intravenous 
injections proved harmless. The gravity of symptoms following subcuta- 
neous injections was commensurate with the quantity of fluid injected. 
Guinea-pigs proved less susceptible to infection than rabbits. In the pus 
taken from the dead tissue he found, besides the usual pus-microbes, a 
bacillus which resembled in every respect the one described by Nicolaier 
and Eosenbach. Hochsinger made his observations on a case of tetanus 
which proved fatal on the fifth day. The day before the patient died blood 
was abstracted from a vein, under strict antiseptic precautions, for micro- 
scopical and bacteriological study. Xo microorganisms could be found in 
it, AVith the greatest care, sterilized, solid blood-serum was inoculated 
with the blood, by making, with the needle, both superficial streaks and 
deep punctures. The nutrient medium w T as kept at a temperature of 
37° C. (98.6° F.). On the third day a white, cloudy streak marked the 
direction of the deep punctures, while the superficial plant remained 
sterile. On the same day a portion of the culture was removed and stained 
with aniline gentian, and the characteristic bacillus was found. A large 



440 PRINCIPLES OF SUEGEEY. 

rabbit was infected by injecting blood obtained from the patient during 
life. The blood was diluted with sterilized water, and a syringeful of this 
mixture was injected under the skin in the iliac region, and half of this 
quantity under the skin of the left thigh. The next day the animal was 
quite ill and unable to use the left hind-leg, which was dragged along in 
walking. At this time great nervous excitability was observed, the exag- 
gerated reflex symptoms being especially well marked in the posterior ex- 
tremities, which, on the slightest touch, were thrown into clonic spasm. 
On the following day the animal was found dead. A few hours before 
death well-marked symptoms of tetanus developed. Injections of blood 
from this animal produced no results in other rabbits, and culture experi- 
ments were equally fruitless. A syringeful of inspissated blood of the pa- 
tient, kept for three weeks, thrown under the skin of a white mouse, was 
followed by a fatal attack of tetanus, while a second animal inoculated 
in a similar manner with one-half of this quantity remained perfectly well. 

Flugge had before observed that, by injecting blood from animals 
rendered tetanic by inoculation, it was necessary to use a large quantity in 
order to reproduce the disease in other animals, and even by doing so 
the result was not always satisfactory. It appears that the blood of te- 
tanic patients possesses greater toxic properties than the blood of animals 
suffering from the same disease. Hochsinger also made inoculations with 
the mixed cultures. A syringeful of a liquid culture was injected into the 
subcutaneous tissue of a medium-sized rabbit. The next day the reflexes 
were increased, respiration more rapid, and the animal appeared otherwise 
quite sick. On the third day the posterior extremities were stiff, the ani- 
mal dragging them in walking; reflex irritability enormously exaggerated. 
On the fifth day the animal died, with well-marked symptoms of tetanus. 
A number of similar successful experiments are reported by the same 
author. In rabbits Flugge estimated the stage of incubation at from three 
to five days, and the duration of the disease, from the time the first symp- 
toms were noticed to the fatal termination, from five to seven days. 

Beumer gives an accurate and able description of his studies in 2 
cases of tetanus. The first case occurred in a mechanic, who injured 
himself under the nail of the right middle finger with a splinter of wood. 
Eight days after the injury, the patient having had but slight pain in the 
finger, pains appeared in the neck and muscles of the back. .The next 
morning spasms of the muscles of the chest, abdomen, and jaw developed. 
These attacks occurred at intervals of an hour and a half. Four days later 
the lower extremities were affected, also the upper, but in a less degree. 
An incision was made and the foreign body removed, which was followed 
by the escape of a drop of pus; death on the fourth day. The second case 
was a boy 6 1 / 2 years old, who was brought into the clinic with well-marked 



BACTERIOLOGICAL STUDIES. Ill 

symptoms of tetanus, and who lived only a few hours after his admission. 
The author obtained some of the dust and splinters of wood from the 
place where the mechanic had injured himself, and inserted small particles 
under the skin of mice and rabbits. In all experiments the animals were 
attacked with tetanus in from two to three days after inoculation, and died 
during the third or fourth. The spasms were always noticed first in the 
muscles nearest the point of inoculation. A fragment of tissue from the 
sole of the foot was taken from the boy, and small particles of it inserted 
into the subcutaneous tissue of 6 mice. In all of these symptoms of tet- 
anus appeared after two days, developing gradually into general convul- 
sions and death. 

The same results were obtained in mice and rabbits by inoculations 
of particles of dust taken from the spot where the boy sustained the in- 
jury. The same author also made numerous experiments with different 
kinds of earth. Of 10 experiments with soil taken from the ocean-beach, 
tetanus followed in only 2. On the other hand, of 10 inoculations with 
garden-earth and street-dust, all proved successful but 1. Of the greatest 
scientific and practical interest are the observations made by Bonome, in 
reference to the causation of tetanus by infection with earth containing 
the bacillus discovered by Xicolaier. He had an opportunity to observe 
a number of cases of tetanus after the earthquake at Bajardo. Of the 
70 persons injured in the ruins of the church, 7 were attacked by tetanus. 
From bacteriological investigations in connection with these cases he 
came to the same conclusions in regard to the cause of the disease as 
Xicolaier, Eosenbach, Fliigge, and Beumer before him. Of special im- 
portance is the observation made by him, that the secretions from the 
wounds and the exudation from the part, the seat of tetanic convulsions, 
when dried and preserved between two sterilized watch-glasses, retained 
their virulent properties for at least four months. All animals inoculated 
with dust from the debris in the interior of the church were attacked with 
tetanus. Control experiments with dust from the ruins at Diano-Marina 
were always followed by negative results. Of the many persons injured 
during the same earthquake at this place, not one was attacked by tetanus. 

Ohlmuller and Goldschmidt made a thorough bacteriological investiga- 
tion of a case of tetanus following complicated fracture of the right thumb. 
The disease appeared the day following the injury, and proved fatal in 
seventeen hours. Soon after death inoculation experiments were made 
with blood taken from the heart and spleen, and pus from the seat of 
fracture. The cultures were grown in solid blood-serum kept at a tem- 
perature of 38° C. (100.7° F.). The tubes containing blood from the 
heart and spleen remained sterile, but the nutrient media infected with 
pus showed signs of growth. The bacilli which were detected resembled 



442 PRINCIPLES OF SURGERY. 

those of mouse-septicaemia, only somewhat larger in size'. In addition to 
these microbes streptococci and a thick bacillus were found. Two mice 
were inoculated with this mixed culture. Twelve hours after infection 
tetanus developed, followed by death in seventeen hours. The spasms 
commenced in the tail, extended to the posterior extremities, and then 
gradually advanced in a forward direction. From these animals blood- 
serum was taken, with which other mice were infected. Again tetanus 
was produced, and successful cultivations were made from 2 mice of equal 
size and age; 1, which received one portion of a culture, died of tetanus 
on the ninth day, while the other, which received a dose three times as 
large, died on the third day. Of 3 cases of tetanus which came under the 
observation of Lumniczer, he was able to demonstrate the microbic origin 
in 1. In this case the attack followed a gunshot injury. After the disease 
had developed fragments of hemp were removed from the canal made by 
the bullet, and in them the characteristic bacillus was found. Cultures were 
made to the tenth generation, and with them animals were inoculated, and 
tetanus was invariably produced. Pus taken from abscesses produced at the 
point of inoculation contained the bacillus, and inoculation experiments 
made with it yielded positive results. Cultures made from the blood or or- 
gans of the tetanic animals remained sterile. Inoculations with blood from 
these animals proved harmless. 

Kitasato experimented with a pure culture of the bacillus of tetanus 
on mice, rats, guinea-pigs, and rabbits, and never failed in producing the 
disease, provided a sufficiently large dose of the culture was adminis- 
tered. In mice the disease appeared, without exception, twenty-four hours 
after the inoculation, and proved fatal in two to three days. The tetanic 
convulsions were first always local, appearing first in the muscles nearest 
the point of inoculation, and becoming gradually more diffuse. He was 
unable to find the bacillus at the seat of inoculation, the blood, or in any 
of the internal organs. He is of the opinion that if tetanus is produced by 
inoculation with a pure culture the bacilli do not remain in the body for 
any length of time, but are rapidly eliminated. The experiments and 
clinical observations which have just been quoted furnish conclusive proof 
that tetanus is a microbic disease, and that the bacillus of tetanus dis- 
covered by Mcolaier and Eosenbach is its essential cause. Whether culti- 
vations from chronic cases of tetanus can produce an acute and rapidly- 
fatal attack in animals remains to be determined. In this direction I 
made an observation which, if not convincing, is at least very suggestive. A 
boy 15 years of age, previously in good health, was attacked with acute osteo- 
myelitis in the lower extremity of the femur. The surgeon in attendance 
trephined the bone just above the external condyle during the first few days, 
and before an abscess had formed in the soft parts. A few days after the 



BACTERIOLOGICAL BTUDIES. 443 

operation trismus sot in. followed by typical chronic tetanus. Six weeks later 
the patient came under my care. At this time the patient had become 
emaciated to a skeleton. 

Trismus and opisthotonos were well marked, and the lower extremi- 
ties were rigid and fixed in the extended position. The slightest touch, 
or a draught of air in the room, would bring on intense convulsive attacks 
for several minutes, attended by excruciating pain. Profuse, fetid dis- 
charge at the site of operation; pulse, 140; temperature, from 99° to 
101° F. (37.3° to 38.8° C). Believing that the primary infection had 
taken place through the operation wound, and that the osteomyelitic 
products served the purpose of a nutrient medium for the bacillus tetani, 
I determined to operate in spite of the grave symptoms. As the spinal 
cord at this stage of the disease was necessarily the seat of intense con- 
gestion, I resorted to chloroform as an anaesthetic in preference to ether. 
The usual operation for necrosis of the lower end of the femur was made, 
and a large triangular sequestrum removed from the lower and posterior 
aspect of the bone. The involucrum was defective, and its inner surface 
was found lined with a thick layer of flabby granulations. Gelatin tubes 
were inoculated with blood, pus, and granulation-tissue. The tube inocu- 
lated with blood remained sterile, while the two remaining tubes showed 
a copious growth of staphylococcus pyogenes albus, which rapidly liquefied 
the gelatin. A portion of the granulation-tissue was disinfected with a 
weak solution of carbolic acid, dried betAveen layers of antiseptic gauze, 
and inserted under the skin of a full-grown, large rabbit. No suppuration 
followed, and the animal remained perfectly well for six weeks, when both 
posterior extremities became rigid and could not be used in walking. The 
next day tetanic convulsions affecting the muscles of the back and all the 
limbs appeared, and on the fourth day death supervened. 

The interesting features in this case are that the patient recovered 
from the tetanus after a long illness, extending over three months; that 
marked improvement followed the operation, which had for its object 
thorough disinfection of the infection-atrium; and that the inoculation 
with granulation-tissue in the rabbit was followed by an acute attack of 
tetanus after an incubation stage extending over six weeks. In the ex- 
periments related above the animals were inoculated with cultures, earth, 
other infected foreign substances, fragments of diseased tissue, or with 
wound-secretions from tetanic patients; the stage of incubation rarely ex- 
tended over two or three days, and often the spasms appeared in eighteen 
to twenty-four hours, and the disease produced death in from two hours 
to three days. 

The same question has been raised in connection with the pathogenic 
action of the bacillus of tetanus as with pus-microbes: Is the disease of 



444 PRINCIPLES OF SUEGEEY. 

which it is the specific cause due to the presence of the microbe, or the 
toxins which it elaborates in the tissues? 

Toxins of the Bacillus Tetani. — Brieger, by his indefatigable labors, 
has demonstrated beyond all doubt that the toxins of the bacillus of tet- 
anus cause tetanic convulsions. Strychnia in toxic doses produces a con- 
dition which, so far as the muscular spasms are concerned, closely re- 
sembles tetanus. If this and other drugs belonging to the same group can 
act upon the spinal cord in such a manner as to cause spasms and mus- 
cular rigidity, we should, a priori, expect that if the microbe of tetanus 
produce toxins in the tissues these might produce the same effect on the 
cord, and that the symptoms are produced by them and not by the direct 
action of the microbe. Nearly all authorities are agreed that the bacilli 
present in the blood of tetanic patients are few, and in animals in which 
the disease was produced artificially the blood was often found sterile. 
More microbes have been found at the seat of primary infection, and in 
the tissues between it and the spinal cord, than in the blood itself: an- 
other proof that the direct cause of the disease is the product of the 
microbes, and not the microbes themselves. Brieger has succeeded in 
isolating four toxic substances from mixed cultures of the tetanus bacillus 
in sterilized emulsion of meat. The first, tetanin, in doses of a few milli- 
grammes, administered subcutaneously in mice, produced the characteris- 
tic symptoms of tetanus. The second, tetomotoxin, causes, first, tremors; 
later, paralysis and convulsions. The third, muriate of toxin, has not been 
designated by a special name; it produces also well-marked symptoms of 
tetanus, but, besides, excites the salivary and lacrymal glands to in- 
creased functional activity. The last, spasmotoxin, produces severe clonic 
and tonic spasms, which prostrate the animal at once. Besides meat- 
emulsion, the contused brain-substance from horses and cattle was used; 
also cows' milk mixed with carbonate of lime. It seems that the" culture- 
substance determined, to a certain extent, the kind of toxin which was 
produced; thus, in cultures grown in brain-substance, besides the tetanin, 
tetanotoxin was found in greatest abundance; old cultures, in which the 
tetanus bacilli were dead, produced none of these toxic substances. 

The same author has also been successful in isolating tetanin from 
the amputated arm of a patient the subject of tetanus. The disease had 
developed a few days after a severe crushing injury of the hand and fore- 
arm. The first symptoms manifested themselves in the morning, and at 
12 o'clock (noon) the operation was performed; at 5 o'clock on the 
same day the patient expired suddenly during one of the tetanic convulsions. 
The bacilli of tetanus were found in the serum taken from the cedematous 
portion of the forearm, in connection with other bacilli of different length: 
staphylococci and streptococci. Serum containing these microbes injected 



BACTEBIOLOGICAL STUDIES. 1 15 

under the skin of mire, guinea-pigs, and rabbits invariably produced tetanus. 
On the other hand, a dog treated in the same manner, as well as after in- 
jections of tetanin, remained well. A horse inoculated with a culture of 
bacilli in meat-emulsion showed no symptoms of tetanus, but an abscess 
formed at the poini of inoculation. The infiltrated tissues of the amputated 
arm planted on sterilized meat-emulsion, solid blood-serum, and emulsion 
made of the flesh of fish, yielded, besides ammonia, only tetanin; no trace 
of U'tanotoxin, spasmotoxin, nor the unnamed toxin which could be obtained 
from Eosenbaclfs bacillus. A moderate dose of tetanin injected into the 
subcutaneous tissue of a horse produced muscular contractions which lasted 
for a considerable length of time, but the characteristic symptoms of tetanus, 
as witnessed in horses suffering from tetanus, did not appear. 

Pestana obtained the toxin of the tetanus bacillus from a pure culture 
in bouillon in the absence of air, which was preserved at a temperature 
of 38° C. for nineteen days, and was then filtered through a porcelain 
filter. Careful examination of the filtrate showed that it contained no 
bacilli. Experiments were made on guinea-pigs and mice; the guinea- 
pigs were used for the direct injection of the toxin obtained from the 
cultures; the mice were employed to determine the toxicity of the blood 
and different organs of the guinea-pigs which received the filtrate. One 
drop of toxin injected under the skin of the thigh of a guinea-pig caused 
tetanus at the end of twelve hours and death in twenty-four hours. One- 
twentieth of a drop produced in mice all the symptoms of the disease in 
eighteen hours and death in thirty-eight hours. In order to study the 
diffusion of the toxin in the body inoculations were made at variable 
periods after injection of the toxin and with the blood and different organs 
of the infected animal. In the first series of experiments 7 drops of toxin 
were injected under the skin in the sacral region of a guinea-pig. As soon 
as symptoms of tetanus showed themselves the animal was killed by 
cutting the carotid. The blood obtained was injected in different quan- 
tities under the skin of a number of mice. A trituration of the different 
internal organs and muscles, each made separately and diluted with a 
saline solution, was injected in another set of mice. Tetanus and death 
were uniformly produced in the mice injected with 15 or more drops of 
blood, and also in those which had been inoculated with the emulsion of 
the muscles from the region of injection. The other animals remained in 
perfect health. In the second series the guinea-pig was killed in a similar 
manner after the tetanic convulsions had become general. One cubic 
centimetre of blqod and half this quantity of the emulsion of a small por- 
tion of the liver produced tetanus, causing death of the mice at the end 
of forty-eight hours with all the symptoms of the disease. The tritura- 
tions prepared from the other organs and tissues produced no effect except 



446 PRINCIPLES OF SURGERY. 

that from the muscles of the region injected, which always gave positive 
results. In the third set of experiments the injections were made after 
the death of the guinea-pig with emulsions of the organs, of the blood, 
and of clots found in the heart, and in these only the liver contained 
enough toxin to produce tetanus. These experiments tend to prove that 
the toxin rapidly enters the blood, and that later it accumulates in the 
lungs, spleen, kidney, but principally the liver, and that it is not elimi- 
nated to any appreciable extent by the urine. Notwithstanding the strik- 
ing predominance of neuro-muscular phenomena in tetanus, the presence 
of toxin in nervous and muscular tissue cannot be shown; all the experi- 
ments made with these tissues yielded negative results. 

ETIOLOGY. 

The clinical and experimental researches just quoted demonstrate 
that the bacillus tetani is found in the wound-secretions, the tissues, and, 
in some instances, in the blood of tetanic patients, and that tetanus in 
animals can be produced artificially by injections of wound-secretions of 
tetanic patients, or by using mixed or pure cultures: facts which have 
firmly established the microbic nature of the disease. The essential cause 
of tetanus is the bacillus first discovered by Xicolaier in earth, and by Eosen- 
bach in the wound-secretion of a tetanic patient. 

Period of Incubation. — The period of incubation, both in man and in 
animals, appears to be extremely variable, in some instances lasting only 
twenty-four hours, while in others weeks may elapse between the time of 
infection and the first manifestations of the disease. This may depend 
on one of three things: 1. The number of bacilli introduced may be so 
small that a much longer time is necessary before active symptoms are 
produced than if a larger quantity had been introduced, as Watson Cheyne 
has shown that in animals the injection of a limited number of the bacilli 
of tetanus produced no symptoms. 2. The location of the infection-atrium 
and anatomical characteristics of the tissues surrounding it may influence 
the time which is necessary to develop the disease. 3. Brieger's investiga- 
tions have shown that tetanic convulsions in animals are produced by in- 
jections of tetanin, — one of the toxic substances derived from cultures 
of the bacillus of tetanus; and it is more than probable that the active 
symptoms of tetanus in man are due not to the presence in the tissues of 
the bacillus, but to the toxic action of the toxins on the spinal cord; so 
that the duration of the period of incubation is further modified by the 
capacity of the infected tissues to yield the different toxins. The degree 
of virulence of the bacillus of tetanus must certainly play an important 
part, not only in determining the duration of the incubation-stage, but 
also the gravitv of the disease. 



ETIOLOGY. 447 

Specific Microbic Cause. — There can bo no doubt that both the acute 
and chronic forms of tetanus are caused by the same microbe, and that the 
clinical difference depends upon the degree of virulence of the primary 
cause on the one hand, and the degree of susceptibility of the individuals 
to tetanic infection, on the other. 

In reference to the susceptibility to infection with the bacillus of 
tetanus, it has been shown by reliable statistics that the colored races, 
under the same conditions, are attacked more frequently by tetanus than 
the Caucasians. Inoculation experiments have shown that the greatest 
difference exists among different kinds of animals in this respect, and 
there is no reason why the same difference of susceptibility to this disease 
should not exist in the human species. As the natural habitat of the 
bacillus of tetanus is the soil, we can readily understand that the disease 
should occur more frequently in some localities than in others, and why 
it is more prevalent in southern than northern climates. The excretions 
and cadavers of tetanic animals may infect the soil, where, under favor- 
able conditions, the bacillus may multiply, and in this manner a greater 
or less portion of the surface soil becomes a nutrient medium, in which 
an immense culture is developed from which new cases can become in- 
fected. A warm climate is more favorable for the unlimited reproduction 
of the bacillus in the soil than northern countries; hence the greater 
prevalence of this disease in the tropics. 

Infection-atrium. — As the bacillus of tetanus is the essential cause 
of the disease, the remaining causes are accidental conditions, which result 
in the formation of an infection-atrium. We have no reliable evidence that 
the bacillus can enter the tissues through an intact mucous membrane or un- 
broken skin. Idiopathic tetanus, so called, is a clinical form of tetanus 
where even the most thorough examination reveals no infection-atrium. 
As in cases of erysipelas, under similar circumstances, the local lesion may 
have been so insignificant as not to have attracted the patient's attention, 
or, if he was cognizant of it at the time, it may have completely disap- 
peared at the time the first s3 T mptoms developed themselves. 

In trismus sire tetanus neonatorum infection undoubtedly takes place 
through the umbilicus. In a case of this kind Beumer found the tetanus 
bacillus in the tissues. There is hardly an operation, capital and minor, 
which has not furnished its quota to the long list of tetanic patients. It 
has been observed most frequently after amputation, castration, and ex- 
tirpation of the thyroid gland. 

Weiss reported 13 cases of tetanus occurring after extirpation of the 
thyroid gland. He attributes the frequency with which this disease follows 
the removal of this organ to irritation of peripheral nerves induced by the 
numerous ligatures. Middeldorpf observed paralysis of the facial nerve in 



448 PRINCIPLES OF SURGERY. 

some of these cases: a circumstance which would indicate a central origin 
of the disease. In 53 total extirpations of the thyroid gland for goitre 
made by Billroth, tetanus followed in 12 cases, while no cases occurred 
in 109 partial operations. Two cases became chronic, in which the disease, 
at the time von Eiselsberg made the report, had lasted for six and nine 
years. In 7 cases there was, besides the ordinary characteristic symptoms, 
an involvement of the muscles of the face, neck, larynx, diaphragm, and 
abdomen; so that dyspnoea and even loss of consciousness occurred. In 
the fatal cases the duration of the disease was from three to thirty days, and 
in 1 case seven months. 

Quite a number of cases have been reported during the last few years 
where tetanus occurred after abdominal section. Tetanus occurring after an 
operation must be the result of infection through the operation wound 
with the specific bacillus, which, without exception, takes place by contact. 
As the bacillus of tetanus is not a pyogenic microbe, it is not necessary 
that a wound through which infection has occurred should suppurate. 
When suppuration takes place it is in consequence of a mixed infection. 
It is a well-known clinical fact that punctured, lacerated, and gunshot 
wounds of the hands and feet are most liable to be followed by tetanus. 
Before it was known that tetanus is a microbic disease, the frequency 
with which this disease complicated such injuries was explained upon 
the ground that the part injured was abundantly supplied with sen- 
sitive nerves, and that the irritation caused by the injury provoked the 
disease. As thousands of operations upon the hands and feet performed 
under aseptic precautions have not resulted in a single instance in tetanus, 
this explanation is no longer tenable. The antiseptic treatment of wounds 
has greatly diminished the frequency of tetanus as a complication of opera- 
tion wounds. Experience has shown that the same treatment which pre- 
vents suppuration and other wound-infective diseases has also diminished 
the frequency of tetanus. Wounds of the hands and feet are so often fol- 
lowed by tetanus, because, in the first place, the implement or substance 
which inflicts the wound is frequently contaminated with infected earth 
or dust, and, in the second place, such wounds are often neglected and 
exposed to subsequent infection from the same sources; and, lastly, in- 
fected foreign bodies are often allowed to remain in the wound. In a 
number of instances animals were successfully infected by inserting 
under the skin particles of foreign bodies removed from tetanic patients. 
Wounds of the hands and feet are no more liable to cause tetanus than wounds 
in any >other part of the tody provided they are not exposed to greater rish of 
infection. Infection through the uterus after abortion and during child- 
bed has been repeatedly observed. 

Gautier has collected 74 cases of tetanus, 36 following abortion and 



SYMPTOMS AND DIAGNOSIS. 449 

38 following confinement. Autopsies were made in 15 cases; 3 presented, 
on microscopical examination of the brain and cord, no appreciable lesion; 
in 1 case a retained putrefied placenta was found in the uterus; in 5 sup- 
purative metritis or salpingitis; in 1 ovarian cyst. The other autopsies 
showed hyperemia of brain, cord, and meningitis; in 1 haemorrhage into 
the lateral ventricles. Ten patients recovered: 5 after abortion, 5 after 
labor. 

Frost gangrene is especially prone to be followed by tetanus. Of 375 
cases of tetanus collected by Thamhayn, the disease followed wounds of 
the fingers and hand in 27 per cent.; of the thigh and leg, 25 per cent.; of 
the toes and foot, 22 per cent.; of the head, face, and neck, 11 per cent.; 
of the arm and forearm, 8 per cent.; and of the trunk, 6 per cent. Of 700 
eases collected by the same author, the disease was known to have followed 
a trauma in 603. As males are more frequently exposed to injury than 
females, the disease is correspondingly more frequent in that sex. The 
largest number of tetanic patients are found among persons from 10 to 30 
years of age, although no age is entirely exempt. According to Larrey, 
Cullen, and Dupuytren, the disease is always aggravated by drafts of cold 
air. That the disease is never caused by exposure to cold requires no argu- 
ment; that drafts of cold air aggravate the disease when it exists is unques- 
tionable, as every peripheral irritation cannot fail in aggravating the mus- 
cular spasms. 

SYMPTOMS AND DIAGNOSIS. 

The toxins of the bacillus of tetanus act upon the brain and the spinal 
cord in a somewhat similar manner as strychnine. If the spinal cord is in- 
jured strychnia acts only upon the parts supplied with nerves from the 
intact portion of the cord. If the posterior roots of the spinal nerves are 
divided it produces no spasms in toxic doses. If in an animal the brain 
and medulla oblongata are removed the effect of strychnia upon the mus- 
cles is not impaired. Injection of hydrate of chloral arrests the spasm pro- 
duced by strychnia, and, consequently, chloral must be considered as the 
most efficient antidote to strychnia. Even the most acute cases of tetanus 
begin insidiously. The patient, perhaps, complains of a sensation of chilli- 
ness and a feeling of soreness about the region of the neck, and shooting 
pains and stiffness in particular muscular groups. The first symptom which 
announces the onset of this dreadful disease is difficulty in mastication. The 
patient discovers, accidentally, that he is unable to open the mouth suffi- 
ciently to drink or grasp the food. On inspection nothing abnormal is 
found, but on trying to separate the teeth the masseter muscle on each side 
becomes rigid and prominent. This spasm of the muscles of mastication is 
called trismus. It is the first group of muscles affected by the central lesion 



450 PRINCIPLES OF SURGERY. 

produced by the toxins of the tetanus bacillus. If other causes of this con- 
dition, such as inflammatory lesions in the pharynx and the alveoli of the 
maxillary bones, can be excluded, the existence of trismus is almost a pathog- 
nomonic symptom of tetanus. The patient next complains of difficulty in 
swallowing, as the muscles of deglutition become affected. The next mus- 
cular groups to become involved are the muscles back of the neck and the ex- 
tensors of the spine, giving rise to retraction and fixation of the head and 
overextension of the spine : conditions which, when well developed, produce 
what is called •opisthotonos. In well-marked opisthotonos the body rests on 
the occiput and heels when the patient is in the dorsal position. If the body 
is bent in an opposite direction, from contraction and rigidity of the ante- 
rior pectoral and abdominal muscles, the condition is called emprosthotonos. 
Contraction of muscles on the side of the chest and abdomen gives rise to 
pleurosthotonos. Orthotonus means tonic spasm and rigidity of all the volun- 
tary muscles: a condition frequently present in advanced cases of tetanus. 
The face of tetanic patients presents a characteristic mask-like appearance 
from the contraction and rigidity of the facial muscles. The muscular 
spasms are clonic, and are always aggravated by the slightest causes, as walk- 
ing in the room; touching the bedclothes or the body of the patient; drafts 
of air; sudden, unexpected noises. The affected muscles are rigid from 
tonic contraction, but this state of rigidity is increased by the paroxysmal 
clonic spasms. 

In acute cases the temperature soon rises to 40° to 41° C, and the 
pulse is correspondingly increased in frequency. The temperature curve 
shows but little change during twenty-four hours. The sensorium usu- 
ally remains unaffected throughout the entire course of the disease. As the 
patient finds it difficult to clear the mouth, the profuse salivary secretion 
escapes from the mouth. Eespiration is impeded in proportion to the num- 
ber of the respiratory muscles affected. In severe cases early dyspnoea and 
cyanosis are present. Special senses remain intact. The pain is most ex- 
cruciating, extending from the neck and back in the direction of the nerves, 
leading to the affected muscular groups. The pain is always aggravated with 
the increased convulsive movements, resulting from the action of external 
irritants. 

In consequence of deficient food-supply, the intense pain, and loss of 
sleep, rapid emaciation and loss of strength appear as early and constant 
symptoms. Approaching exhaustion is announced by profuse clammy per- 
spiration, coldness of the extremities, and a rapid, feeble, and intermittent 
pulse. As soon as the intercostal muscles are affected respiration becomes 
more and more embarrassed, and when, finally, the diaphragm is thrown into 
a tonic spasm respirations and pulse cease, general cyanosis follows, and 
death may ensue during the first spasm of the diaphragm. Should, how- 



CLINICAL FOHMS OF TETANUS. 451 

ever, the patienl rally from this attack, he will be almost certain to succumb 
to the second or third attack. 

Wnnderlieh lias seen the temperature shortly .before death rise to 42° 
or 43° C, and the same has been observed in animals dying from tetanus 
by Billroth, Kick, and Leyden. A post-mortem rise in temperature to 44.7° 
C. has been recorded by Wnnderlieh, and he attributed this strange phe- 
nomenon to paralysis of the central heat-moderators. In chronic tetanus 
the disease commences very insidiously, and the graver symptoms, such as a 
very high temperature, feeble and intermittent pulse, spasm of the inter- 
costal muscle and diaphragm, are absent. The temperature is normal or 
only slightly elevated. Trismus is always present, to which may be added 
spasm and rigidity of the muscles of the back of the neck and the extensors 
of the spine. The trismus makes it difficult to administer food in sufficient 
quantity, and, on this account, progressive emaciation is one of the promi- 
nent features of this form of tetanus, as the disease, as a rule, lasts from 
six to ten weeks. The disappearance of symptoms is as gradual as their 
onset. In the differential diagnosis it is important to distinguish between 
tetanus and strychnia poisoning, hysteria, catalepsy, hydrophobia, cerebro- 
spinal meningitis, and basilar meningitis. With few exceptions it is pos- 
sible in tetanus to establish the fact of infection, and the clinical history 
shows that different muscular groups become involved successively in regu- 
lar order, first trismus, then rigidity of the muscles at the back of the neck, 
and, finally, opisthotonos. In acute cases the disease is attended by a con- 
tinuously high temperature. In strychnia poisoning the maximum symp- 
toms, opisthotonos or orthotonos, are developed suddenly, as soon as a toxic 
dose of the drug has been absorbed. The convulsive movements in hysteria 
are not limited to any definite muscular groups, and the pulse and tempera- 
ture are normal. The same can be said of catalepsy. In hydrophobia, as 
we shall see subsequently, the spasms are limited to the muscles of degluti- 
tion, the stage of incubation is longer than in tetanus, and infection is al- 
ways caused by the bite of a rabid animal, usually a dog. In cerebro-spinal 
meningitis muscular spasm and rigidity are limited to the extensor muscles 
of the spine; so that, even if the disease has caused well-marked opisthotonos, 
trismus is absent. Tubercular meningitis is usually ushered in by intense 
headache, vomiting, and photophobia, and if tonic muscular spasms set in 
they affect the muscles at the back of the neck almost exclusively. Trismus 
is never present. 

CLINICAL FORMS OF TETAXFS. 

Acute Tetanus. — The stage of incubation, as a rule, is shorter than that 
which precedes the chronic form of the disease. Trismus develops grad- 
ually, but after it has once been established the extension of the disease to 
other muscular groups is rapid. A high temperature and rapid, feeble pulse 



452 PRINCIPLES OF SURGERY. 

are always present. Kespiration is mechanically embarrassed by the suc- 
cessive implication of the different muscular groups which are concerned 
in the function of respiration, the last one to become affected being the 
diaphragm. The disease may prove fatal in twenty-four hours, and the dura- 
tion is seldom prolonged for more than a week. 

Chronic Tetanus. — The disease not only commences insidiously, but the 
sjonptoms appear gradually and never develop to the same extent as in acute 
tetanus. The most marked feature is trismus, which may be followed by a 
mild degree of opisthotonos. The muscles of respiration are not implicated, 
and if death result it is from marasmus and exhaustion and not from apnoea. 
The duration of the disease is seldom less than six, nor more than ten, weeks. 

Trismus. — Tetanus in which onty the muscles of mastication are affected 
is called trismus. With the exception of the infantile form, trismus is a 
chronic and comparatively benign affection. 

Tetanus Neonatorum. — Tetanus occurring in infants during the first 
week after birth is clinically characterized as trismus, and proves fatal, al- 
most without exception, in a few days. Infection takes place through the 
umbilicus before or after separation of the cord. It is a disease that occurs 
much more frequently in tropical than northern climates, for reasons which 
have been heretofore explained. 

Tetanus Hydrophobics, or Head Tetanus. — This is a form of tetanus 
which was first described by Bernard and Lepine and E. Eose, in 1870. In 
the cases which have been reported it followed head injuries, especially 
wounds of the face. Besides trismus, it is characterized by paralysis of the 
facial nerve on the injured side. Brunner maintains that paralysis of the 
facial nerve, which seems to be a very common symptom on the side of the 
lesion in man, does not occur in experimental tetanus in the lower animals; 
on the contrary, there is in them invariably facial spasm. From his analysis 
of these results and his study of the recorded cases in man Brunner comes 
to the conclusion that in many cases the facial paralysis reported must be the 
result of faulty observation or else an accidental complication not essentially 
belonging to this form of tetanus. He produced typical tetanus by injecting 
subcutaneously blood from the longitudinal sinus and fluid taken from the 
pleural and pericardial cavity of a patient who had died of tetanus hydro- 
phobicus. During deglutition the muscles which are concerned in this act 
are thrown into spasm, and on this account the disease bears a strong resem- 
blance to hydrophobia. Klemm collected 24 cases of this disease. Most of 
them recovered, and in those that died the disease passed into the t}^pical 
form of tetanus. 

PROGNOSIS. 

The most important element in prognosis is the type of the disease. 
The more acute the onset and the more intense the symptoms, the greater 



PATHOLOGY AM) MORBID ANATOMY. 453 

the immediate danger to life, [f death does not occur within two weeks the 
prospect > of an ultimate recovery are good. Of 280 cases which comprise the 
Calcutta statistics ^^ this disease, 1 •"> per cent, proved fatal. This list repre- 
sents about the average mortality of this disease. The greater the excita- 
bility of the motor centres of the spinal cord, and the more rapid the suc- 
cessive involvement of different muscular groups, the greater the danger of 
an early dissolution. In acute cases death is always preceded by great 
dyspnoea, and death usually occurs during an attack of convulsions, in which 
the intercostal muscles and the diaphragm take part. Chronic cases ter- 
minate, as a rule, in recovery after an illness lasting from six to ten weeks. 

PATHOLOGY AND MORBID ANATOMY. 

The absence of gross pathological changes is characteristic of tetanus. 
The only constant lesion found is an hypersemic condition of the medulla 
oblongata and the spinal cord, to which special attention has been called by 
Leyden, Joffrey, Eanvier, and Eobin. As all of the peripheral manifesta- 
tions of the central lesion point to an increased excitability of the nervous 
centre, we would expect that the principal lesions are to be found in the 
gray substance of the cord. In 1857 Eokitansky described tetanus as an 
ascending neuritis. He found a connective-tissue proliferation, in the form 
of a semifluid, adhesive, grayish substance, between the medullary ele- 
ments of the nerves leading from the infected district. In some cases he 
found extensive destruction of the nerve-tubes, and their space occupied 
by the products of granular degeneration: colloid and amyloid corpuscles. 

Lockhart-Clark and Dickinson found, as the most constant pathological 
lesion, inflammatory softening of the gray substance of the cord and dilata- 
tion of the vessels. Michaud and Benedict found cell-proliferation into the 
anterior cornua of the cord and great vascularity. Elischer regarded the 
central lesion as a myelitis with vacuolation in the ganglia-cells. Tyson 
found in two cases destruction of the central canal of the cord, with disin- 
tegration of the posterior cornua. Aufrecht narrowed the morbid anatomy 
of tetanus down to atrophy of the anterior horns, in the cervical portion of 
the spinal cord. Schultze was never able to discover any evidences of mye- 
litis. The hyperemia of the cord, which is so constantly found, may be the 
result of a passive congestion; at present this cannot be accepted as proof 
of inflammation, because in most cases the anatomical and clinical evi- 
dences do not sustain this supposition. The view that tetanus is essentially 
an ascending neuritis, as was claimed by Eokitansky, is no longer tenable, 
since it is not supported by the results of recent investigations. Minute 
tissue-changes were found most constantly in the spinal cord. Punctiform 
haemorrhages in the gray substance of the cord are seen frequently, more 
especially in the anterior horns. The chromophilic elements of the nerve- 



454 PRINCIPLES OF SURGERY. 

cells are smaller and altered in shape, in some places they are transformed 
into grannies scattered through the protoplasm of the cell. In some prep- 
arations these elements had disappeared at the periphery of the cells, as has 
also been observed in hydrophobia and in anaemia of the cord from com- 
pression of the abdominal aorta. The achromatic substance is deeper in 
color. In the earlier stage of the disease the nuclei are not much affected, 
but later their interior is less distinct, the coloration more intense, and the 
nuclear net-work obscure. The neuroglia-cells are increased in size. In the 
later stages the degenerative changes extend to the white substance of the 
cord. It is left for future research to furnish more reliable information con- 
cerning the pathology and morbid anatomy of tetanus. At present we can 
only surmise that the toxins of the bacillus act upon the gray matter of the 
cord, where minute lesions are produced, which must account for the clinical 
manifestations of the disease. 

TREATMENT. 

The prophylactic treatment of tetanus has in view the prevention of 
infection by the usual antiseptic precautions in the treatment of wounds 
and local lesions which might become the necessary infection-atrium. As 
tetanus follows more frequently injuries insignificant in themselves than 
large wounds or major operations, it behooves the surgeon to treat the 
minutest lesions with the greatest care and in strict accordance with anti- 
septic principles. Foreign bodies should be carefully searched for and re- 
moved. Even the most recent accidental wounds should be treated as in- 
fected wounds, and should be rendered aseptic by a thorough primary dis- 
infection. The antiseptic treatment must be continued 1 until the wound is 
completely healed, and during this time the injured part must be kept at 
rest. Wounds of the lower extremities must be treated by confining the 
patient to bed, and wounds of the upper extremities demand, in their treat- 
ment, fixation of the limb upon some kind of a splint or, at least, suspension 
in a sling. 

In acute cases of tetanus the most that can be expected from treatment 
is palliation. The excruciating pain is often only relieved by inhalation of 
chloroform. The administration of chloroform should be conducted by the 
physician in attendance or a reliable assistant, and should only be carried 
to the extent of relaxing the contracted muscles, and repeated as often as 
necessary to procure rest. Morphia in doses of x / 4 to 1 / 2 grain, with 1 / 200 
grain of atropia, should be given hypodermically every three or four hours 
until the desired effect is reached. In less severe cases the internal use of 
hydrate of chloral and potassic bromide, each in doses of from 15 to 20 
grains, can be given every three or four hours with excellent effect, Woorara, 
which has been quite extensively used in the treatment of the disease, is 



TfiEATMENT. 455 

absolutely contraindicated, as its paralytic effect on the heart cannot fail in 
producing anything but a deleterious effect. 

Fancel and Frache report a case of tetanus successfully treated by hypo- 
dermic injections of carbolic acid after the usual treatment by bromide of 
potassium and hydrate of chloral had failed to ameliorate the symptoms. 
The dose consisted of 1 centigramme every two hours, and the treatment 
was continued for seventeen days. The effect was almost immediate, the 
spasms becoming much less violent and less painful and the patient's general 
condition showing marked improvement. The authors refer to the intro- 
duction of this mode of treatment by Baccelli, who reported a case in which 
he had employed it successfully in 1888. They do not, however, agree with 
him in attributing the efficacy of treatment to the sedative action of the 
carbolic acid on the spinal centres, but regard it as due to the parasiticide 
power of the remedy. 

Deep injections of a 2-per-cent. solution of carbolic acid in the course 
of the principal nerves is the method employed. Experience has shown 
that tetanic patients are very tolerant to the action of carbolic acid, and yet 
care is required not to carry the treatment far enough to endanger the life 
of the patient by drug intoxication. Ascoli cites 35 cases of tetanus treated 
by parenchymatous injections of carbolic acid with only 1 death. The 
initial dose is about 3 grains a day, which is rapidly increased to 6 or 8 
grains a day. 

The following remarks on the treatment of tetanus with antitoxin are 
taken from a valuable paper on this subject from the pen of R. T. Hewlett, 
published in The Practitioner: — 

"The method of preparing the tetanus antitoxin is similar to that 
employed in obtaining'the diphtheria antitoxin. In practice it is met with 
in at least three forms: (1) the blood-serum, as such is sometimes used; (2) 
the dry form, 1 gramme of the dry substance corresponding to 10 cubic 
centimetres of the fluid serum; (3) the serum may be precipitated with 
alcohol and the precipitate dried, — Tizzonfs antitoxin. This last is, per- 
haps, the most concentrated form. 

"Dose of the Antitoxin.- — It is difficult to state definitely what should 
be the dose, for this has varied enormously in the published cases. The 
smallest dose recorded is 5 or 6 cubic centimetres, the largest 167 cubic 
centimetres, which was given in one instance by Eoux; and it is remark- 
able that this enormous amount gave rise to no disturbance except urti- 
caria, which is also a frequent phenomenon with the diphtheria antitoxin. 
Of the fluid serum, which should have an immunizing power of at least 
1,000,000, I Should be inclined to recommend 20 to 40 cubic centimetres 
for the first dose, followed by 10 to 20 cubic centimetres every six or twelve 
hours afterward. Of the dried serum, 1 gramme corresponds to 10 cubic 



45G PKINCIPLES OF SURGERY. 

centimetres of the fluid serum, and equivalent amounts are to be adminis- 
tered, — that is, 2 to 4 grammes for the first dose, followed by doses of 1 to 2 
grammes; while Tizzoni recommends 2.25 grammes of his antitoxin for the 
first dose and 0.6 gramme for subsequent doses. The amount and frequency 
of the injection of antitoxin are to be based on the urgency and subsequent 
amelioration or otherwise of the symptoms, it being borne in mind that, the 
shorter the incubation period, the more acute will probably be the course 
of the disease. 

"Administration of the Dose. — The serum must be administered en- 
tirely by subcutaneous injections. The syringe should be a large one, with 
the capacity of at least 10 cubic centimetres, an ordinary-sized hypodermic 
syringe necessitating multiple punctures. Before using the syringe it should 
be taken to pieces and sterilized, and the skin to be punctured should be dis- 
infected with l-to-20 carbolic lotion. If the fluid serum be employed the 
requisite amount should be poured out into a measure previously rinsed with 
boiling water to sterilize it, and the vial quickly corked again and kept in a 
cool, dark place, preferably on ice; and if, after being opened once or twice, 
it becomes cloudy from the presence of bacteria, it must be discarded. The 
dried serum and Tizzoni" s antitoxin must be finely powdered, and the dose 
weighed out and dissolved in 5 or 10 parts (according to convenience) of 
distilled water, which has been sterilized by boiling for ten minutes. As 
heat is fatal to the antitoxin, no warmth must be emplo} r ed to hasten solu- 
tion; and syringes, vessels, etc., ought to be allowed to cool after sterilization 
before using. The antitoxin is injected subcutaneously into loose cellular 
tissue, as in the back between the scapulae or in the abdomen. 

"Employment of the Antitoxin (a) as a Remedy. — For the antitoxin 
to have a fair chance it ought to be administered as soon as the onset of 
tetanus is probable. Any distinct sign, such as stiffness of the neck, diffi- 
culty in opening the mouth, or even considerable pain at the seat of injury 
or radiating from it, coming on a few days after the accident without ap- 
parent cause, should at once lead us to employ this remedy. 

"The amount of antitoxin necessary for cure increases very rapidly with 
the duration of the disease, so that it is imperative to employ the remedy as 
soon as possible. 

"(b) As a Prophylactic. — The wonderful power exerted by the anti- 
toxin in rendering the animal body proof against tetanus suggests whether 
it might not be wise in some instances to use it before the disease declares 
itself. For example, a person sustains a lacerated wound which is freely 
soiled with the earth; it is untreated and suppurates, and he comes under 
observation only when matters have gone from bad to worse. Here the onset 
of tetanus might not be unlikely later on, and a small injection of antitoxin, 
judging by the result of experiment, would render this impossible. The 



I RE LTMBNT. 457 

amount sufficient to immunize is much smaller than is required to cure, and 
probably an injection of 5 cubic centimetres of serum would be enough for 
this purpose." 

Kneass has collected from literature 68 cases of tetanus treated by anti- 
toxin, of which 61 are available for statistical purposes, and these give a 
mortality only slightly less than under the older methods of treatment. 
Roux has never seen the least effect of the serum upon the course of the 
disease. Lambert believes in the therapeutic value of the remedy, and agrees 
with Tizzoni that it does not act by neutralizing the active principles of in- 
fection, but by immunizing those parts of the body not already tetanized, 
thus limiting the tetanus locally. He accepts 80 per cent, as a fair state- 
ment of the fatality in tetanus. With Baz}^ Nocard, and others, he is in- 
clined to advise prophylactic inoculations in the treatment of wounds liable 
to give rise to tetanus. This recommendation is based especially upon 
Roux's statement, well supported by experiment, to the effect that the toxin 
can be readily neutralized at the time of infection, but that a very short 
time afterward it requires doses thousands and hundreds of thousands of 
times larger to accomplish the same effect. 

Goldschneider and Flatau found, by using MssFs stain, that the disin- 
tegration of Xissl's chromatophilic elements took place within a very short 
time after the intoxication. Tetanus antitoxin given at a proper time after 
the toxin prevented the changes, when injected after the production of the 
latter it was capable of causing restoration of the ganglia-cells to normal. 

The antidotal effects of the antitoxin could not be more clearly shown 
and the discoveries appear to strengthen the view of the Behring school, 
that toxin and antitoxin neutralize each other. 

Metschnikoff has studied the influence of the central nervous system 
on tetanus toxin, and confirms the results of Wassermann and Takalai. The 
brain-tissue of the guinea-pig protects several times the fatal dose of tetanus 
toxin. 

Tetanus toxin is not destroyed by mixing it with brain-substance, and 
the value of the latter should be attributed to an intervention of the body 
of the inoculated animal. The mixture of brain-substance and toxin pro- 
duces considerable inflammation when injected into the tissues, and this 
reaction attracts leucocytes, which are not only capable of destroying mi- 
croorganisms, but also of absorbing toxic substances. 

The intracerebral injection of antitoxin in the treatment of tetanus has 
been warmly recommended by Kocher. This method of treatment was first 
suggested by Boux and Borrel. They made 45 experiments on guinea-pigs. 
Tetanus was artificially produced, and after the appearance of the first 
symptoms the serum was injected directly into the brain and 35 of the ani- 
mals recovered. In 17 other animals treated by subcutaneous injection of 



458 PRINCIPLES OF SURGERY. 

the antitoxin in much larger doses, only 2 survived. All of the control 
animals died. The combined mortality of tetanus treated by cerebral in- 
jections up to the present time is about 52 per cent. It is doubtful if this 
treatment will receive any encouragement in the future. 

All patients suffering from tetanus should be kept in a quiet, dark 
room, and all kinds of excitement must be carefully avoided, as bodily and 
mental rest are important elements in the treatment. As mastication is im- 
possible, the patient must be nourished with liquid food, which he can sip 
through an elastic tube. If swallowing is impossible, a small elastic tube 
is introduced through one of the nostrils into the stomach, and food is ad- 
ministered at regular intervals by this method. In chronic tetanus warm 
baths are grateful to the patient, and exercise a decided influence in amelio- 
rating the symptoms. The surgical treatment of tetanus has yielded no 
better results than the internal use of drugs. In all cases the infection- 
atrium should be carefully examined, and, if necessary, the wound or local 
lesion should be thoroughly disinfected, as this treatment may be the means 
of preventing further infection from this source. Scars should be excised 
and foreign bodies removed. 

Under the belief that tetanus is an ascending neuritis, nerve-section, or 
neurotomy, has been practiced for the purpose of preventing further exten- 
sion of the inflammation by interrupting the continuity of the nerve; but 
the results, as could be expected, were disappointing, and the operation has 
fallen into well-deserved desuetude. When nerve-stretching was the rage 
in the treatment of all kinds of nerve-affections it was also applied in the 
treatment of tetanus, but the results were no better than after neurotomy. 
Nocht reported 24 cases of tetanus treated by this method, and of this num- 
ber only 4 recovered: the average percentage of recoveries in all cases of 
tetanus not treated by surgical resources. Amputation is only indicated in 
cases where the local conditions which give rise to tetanus make it necessary 
to resort to this operation without reference to the existence of tetanus. 



CHAPTER XVIII. 

Hydrophobia. 

Hydrophobia, lyssa, canine madness, and rabies are synonymous terms 
used to designate a nervous disease caused by the bite of a rabid dog or 
other animal, attended with violent spasms if the patient attempt to swallow 
water or other liquids and by embarrassment of respiration from spasm of 
the laryngeal muscles. This disease never occurs spontaneously in man, but 
is always the result of inoculation with the virus of a rabid animal. Al- 
though this disease never originates elsewhere than in the dog and animals 
belonging to the same species, the wolf, fox, and jackal, the virus of rabies 
is capable of being communicated to all warm-blooded animals. It has been 
estimated that in man the disease is derived in nine out of ten cases from 
dogs; sometimes it is contracted from cats, and sometimes, but very rarely, 
from foxes or wolves. The specific virus of hydrophobia appears to be gen- 
erated in the glandular appendages of the mucous membrane of the mouth 
and throat, and is transmitted by the saliva of the rabid animal. For this 
reason it has been observed that inoculation is more apt to take place from 
a bite on an uncovered part of the body — as, for example, on the hands or 
face — than from a bite inflicted through the clothes, as in the latter case the 
greater portion of the saliva is deposited in the clothing. Not every person 
bitten by a rabid dog necessarily contracts the disease, as statistics have 
shown that about one-third of the animals and human beings bitten by 
mad dogs escape all clanger. This partial immunity is explained in part by 
the virus being diluted, and being wiped from the teeth of the rabid animal 
by clothing; and also by well-ascertained facts proving the absence of sus- 
ceptibility to its action in certain individuals, both in animals and in man. 

Renault's careful experiments proved that one-fourth of the inoculated 
creatures escaped the effects of the inoculations, which were mortal in the 
other three-fourths. As in civilized countries the disease is contracted 
almost exclusively from rabid dogs, it is necessary to call attention to the 
symptoms which characterize the disease in this animal, in order that it may 
be recognized in time, so that the infected animal can be isolated and kept 
in close confinement until the result shall prove or disprove the correctness 
of the diagnosis. It is a great mistake to kill an animal suspected to be rabjd, 
until by careful observation continued for some length of time, or from the 
result of the disease, a positive diagnosis can be made, and thus a great deal 
of unnecessary fear may be avoided. 

(459) 



460 PRINCIPLES OF SURGERY. 

HYDROPHOBIA IX THE DOG. 

The name "hydrophobia," meaning literally a dread of fluids, is a proper 
designation for the disease as it occurs in mam because a peculiar dread of 
fluids is the most characteristic symptom of this disease in the human being. 
This symptom does not exist in the dog: hence, in this animal we should 
speak of the disease as rabies, in man as hydrophobia. Fleming, who is an 
acknowledged authority on everything that pertains to hydrophobia, makes 
the following statement in reference to the ability of rabid animals to take 
fluids: "The many hundreds of rabid dogs seen by Blaine. Youatt, and 
others did not evince any marked aversion to fluids. On the contrary, the 
rabid animal is generally thirsty, and if water be offered will lap it up with 
avidity, and. at the commencement of the disease, will always swallow it. 
"When, at a later period, the constriction about the throat, which is symptom- 
atic of the malady, renders swallowing difficult, the animal does not the less 
endeavor to drink, and lappings are as frequent and prolonged as deglutition 
is retarded. Even then we see the suffering creature, in despair, plunge its 
entire muzzle into the vessel, and gulp at the water as if determined to over- 
come the spasmodic closure of the throat by forcing down the fluid. Tanta- 
lus did not experience a greater torment with regard to water than does the 
unlucky dog.'" The excessive sensibility to pain and the action of the mild- 
est external irritants so characteristic of hydrophobia in the human being are 
absent in the rabid dog. The animal is almost insensible to pain: he will 
dash himself against the bars of his kennel, tear them when his mouth is 
lacerated and bleeding, and he has been known to seize a red-hot poker in 
his mouth and hold on to it. apparently unconscious of suffering. Rabies in 
the dog must be suspected when the animal becomes dull, morose, mopes, 
and avoids his master and companions. During the commencement of the 
disease the animal is exceedingly restless, and is always on the move, prowl- 
ing, snapping, and barking at imaginary objects. During the first two or 
three days there is rarely any tendency on the part of the animal to bite, nor 
to paroxysms of uncontrollable fury. 

The danger in this stage to man and other animals comes from licking 
rather than biting, for there is a propensity to extraordinary demonstrations 
of affection. After a time, however, a paroxysm of maniacal fury comes on, 
generally provoked by the sight of another dog. When this has subsided the 
animal again becomes controllable, but manifests a strange disposition to 
wander from place to place. He is now most dangerous. With a slinking 
and troubled aspect, his head and tail down, his eyes suffused, and foam at 
his mouth, he walks or trots along, snapping and biting at real and imaginary 
objects. He is only aggressive when attacked, and then his fury seems un- 
bounded. When tired out from inadequate nourishment and the ceaseless 
wanderings, he drops exhausted in some out-of-the-way, solitary corner, and, 



BYDROPHOBI.A A MICROBIC DISEASE. 461 

after a rest, starts off again on his lonely journey, seemingly impelled by 
Borne irresistible force, and is finally killed or dies of exhaustion. The dura- 
tion of the disease in the dog never exceeds ten days, and in the majority 

s< s the animal dies on the fourth or the sixth day after the appearance of 
the first symptoms. 

From a study of the symptoms in this animal we can readily distinguish 
three stages: 1. Prodromal. 2. Irritation. 3. Paralytic. During the pro- 
dromal stage the most notable changes refer to the altered habits of the 
animal, while the stage of irritation culminates in attacks of ungovernable 
rage, provoked by real or fancied causes. The last, or paralytic, stage pre- 
cedes death, which takes place from exhaustion. The period of incubation 
in the dog is variable; it is usually from six to twelve weeks, but may extend 
to a much longer period. Frank, from a study of 200 observed cases of rabies 
in the dog, found that the average period of incubation was three months; 
the extremes, six and seven days and eleven months. 

HYDROPHOBIA A MICROBIC DISEASE. 

The microbic cause of hydrophobia remains undiscovered at the present 
time. Bacteriologists have found and described different microbes in the 
tissues of hydrophobic animals, but the direct relationship between any of 
them and the causation of this disease has not been established. That the 
disease is of a microbic origin has been shown abundantly by its commu- 
nicability and the artificial production of the disease in animals by inocula- 
tions with spinal-cord tissue from hydrophobic animals. 

Eaynaud and Lannelongue discovered that rabbits could be successfully 
inoculated with saliva from rabid animals. Pasteur corroborated these ob- 
servations by his own experiments, and cultivated from the blood of the in- 
fected rabbits in veal-bouillon a microorganism which in shape resembled 
the figure 8; this microbe was surrounded by an envelope of a gelatinous 
substance. In the cultures these rods are said to have become converted into 
chain cocci. Fowls and guinea-pigs were not found susceptible to inocula- 
tions with cultures of this microbe. After Pasteur had regarded these mi- 
croorganisms as the cause of hydrophobia, he produced the same disease in 
rabbits by inoculations with saliva from healthy persons. Yulpian also suc- 
ceeded in producing, by inoculations of normal saliva in rabbits, a disease 
which proved fatal in two days; and with a small quantity of blood taken 
from the dead animals the disease could be communicated to other rabbits. 
The disease thus produced was probably the same as that described by Stern- 
berg. This observer caused marked septicaemia in rabbits by injecting sub- 
cutaneously his own saliva in small doses. Injections of 1.25 to 1.75 cubic 
centimetres, with few exceptions, caused death, usually within forty-eight 
hours. The constant and characteristic lesion found was a diffuse cellulitis. 



462 PRINCIPLES OF SURGERY. 

or inflammatory oedema, extending in all directions from the point of in- 
jection, attended with an abundant exudation of bloody serum, swarming 
with micrococci. Hemorrhagic extravasations in the connective tissue, and 
in the various organs, were of frequent occurrence, and changes in the liver 
and spleen, such as are common in rapidly-fatal septic diseases, were gener- 
ally found. The disease could be communicated by dipping an hypodermic 
needle into the blood of a rabbit just dead from the result of an injection 
of saliva; inoculating a healthy rabbit, a rapidly-fatal septicaemia was pro- 
duced. 

Gibier found, in the brain of hydrophobic animals, round, shining 
granules, which stained slowly and imperfectly in aniline dyes. 

Fol stained the brain-substance, according to T^eigert's method, and 
discovered in the hollow spaces of the neuroglia groups of micrococci. The 
same microbe he found also in the nerve-fibres, between the sheath and axis- 
cylinder. Babes stained the specimens according to Gram's method, and 
found cocci in the cells, especially those of the surface of the brain. The 
cocci looked like diplococci, and were always found aggregated in flat clus- 
ters. Fol and Babes claim to have succeeded in obtaining a culture of the 
microbes found in the brain. The former used for nutrient medium a fil- 
trate of triturated brain and parenchyma of salivary gland. Of 8 dogs, rats, 
and rabbits inoculated with the first culture, 5 died of well-marked hydro- 
phobia; of 8 dogs inoculated with the second culture, 4 died. The inocula- 
tions were always made by infecting the brain through an opening in the 
skull. The microbes in the cultures corresponded in shape and size with 
those found in the brain of hydrophobic animals. The third series of cult- 
ures produced only negative results. The microbes in these cultures were 
more readily stained than most of the first two cultures. Babes cultivated 
the microbe upon gelatin and coagulated blood-serum, to which was added 
brain-substance obtained from rabbits. The cultures grew slowly, and ap- 
peared as gray spots. Successful inoculations were made with the second 
and third generations. 

Spinello and Eivolta have recently discovered another microorganism 
in the central nervous system of hydrophobic animals. It is a small bacillus 
and Memino believes that there is no doubt of the etiological relationship 
between this organism and hydrophobia. He succeeded in cultivating it in 
artificial nutrient media and by inoculations with a pure culture reproduced 
the disease in dogs and other animals. He found the bacillus in the cerebro- 
spinal fluid in the substance of the brain and spinal cord, in the saliva and 
parotid gland, and in the aqueous humor of four dogs dying of the disease. 
Fluid media, especially bouillon and glucose acidulated with tartaric 'acid, 
were found best adapted for culture experiments. 

The microbe of hydrophobia exists, but so far it has not been discovered. 



CAUSES. 463 

That hydrophobia is a microbic disease can wo Longer be doubted. At the 

present time we can safely assert, without Eear of contradiction, that the 
essential cause of this disease is a specific virus, which can only be repro- 
duced within the living organism. As a small quantity of this virus intro- 
duced in the tissues can result in the most serious consequences, there exists 
no doubt that it possesses the properties pertaining to living organisms, more 
especially the capacity of reproduction after its entrance into the body. 
That the disease is not caused by preformed toxins, communicated from the 
saliva of rabid animals, is shown by the variable and, on the whole, long 
stage of incubation which precedes all true infective processes. That hydro- 
phobia is not caused by a soluble virus has also been shown by the experi- 
ments of Peuch. He triturated the brain of an hydrophobic animal and 
filtered it under a pressure equivalent to 3 atmospheres. The clear filtrate, 
when injected into animals susceptible to this disease, proved harmless; 
while the residue on the filter, when used in a similar manner, invariably 
produced positive results. Another convincing proof of its microbic origin 
is the well-established fact that the disease can be artificially produced by 
implanting fragments of brain- or cord- tissue, taken from animals dead of 
rabies, into healthy animals. Furthermore, the blood and secretions of a 
rabid animal, its flesh and viscera, even the cooked flesh of a rabid ox, when 
eaten, would seem to be capable of conveying the disease. A pupil at the 
veterinary school of Copenhagen inoculated himself with the virus by cut- 
ting his finger slightly, while examining the body of a dog that had died of 
rabies on the evening before; the studient died of hydrophobia in six weeks. 
The clinical symptoms, as well as the pathological conditions found in the 
brain and spinal cord of hydrophobic patients, bear such a strong resem- 
blance to tetanus that it appears probable that the microbe possesses anal- 
ogous pathogenic properties, and that the actual development of the disease 
follows the action of its toxins upon the central nervous s}<stem. The latent 
stage of the disease, or the long duration of the period of incubation, depends 
either upon the slow growth of the microbes or that these reach the place 
slowly from where they exert their specific pathogenic properties. 

CAUSES. 

The microbe of hydrophobia does not penetrate the intact skin or 
healthy mucous membrane; hence its entrance into the tissues takes place 
through an infection-atrium: usually a punctured wound made by the bite 
of a rabid animal. As the microbe preexists in the saliva of the rabid animal, 
inoculation takes place at the time the wound is inflicted. Infection, how- 
ever, can take place by the deposition of the infected saliva upon a surface 
from which absorption can take place. This can occur from the licking of 
a wound or abraded surface by an infected dog, as happened in one of my 



464 PRINCIPLES OF SURGERY. 

cases. In another case a lad}' of rank and fashion had a pimple on her face, 
from which she had scratched off the head. Hydrophobia was thus con- 
tracted, and she perished by this terrible disease. 

SYMPTOMS AND DIAGNOSIS. 

Great diversity of opinion exists as to the length of the period of in- 
cubation in man. In the 2 cases of hydrophobia that have come under my 
own observation the time of infection and the onset of the disease could be 
accurately fixed, and in both of them the stage of incubation lasted forty-two 
days. In 106 cases of hydrophobia in human beings of all ages, collected 
by Bouley, 23 occurred within two months after infection, and the re- 
mainder came in at varying periods, the longest time noted being eight 
months. The cases reported where it was supposed the disease developed 
some years after the persons were bitten by a dog lack accuracy of obsrva- 
tion, and either the diagnosis was not correct or infection occurred more 
recently, as we have the authority of Fleming that the disease never occurs 
later than eight months after inoculation. Age appears to have some in- 
fluence in modifying the duration of the stage of incubation. In the cases 
where the length of this stage could be accurately ascertained, in patients 
under 20 years of age the mean period of incubation was six weeks; from 
20 up to 72 it was two months and a half. Before the actual development 
of the disease in man there is usually a period of a few days during which 
ill-defined premonitory symptoms can be detected. The wound through 
which the virus entered is the seat of a sensation of uneasiness and itching, 
and sometimes of actual pain, which radiates along the course of the nerves 
of a limb. The cicatrix often presents a congested appearance, and is tender 
on pressure. The patient is melancholic and irritable, and sleep is disturbed. 
The first characteristic symptom of hydrophobia in man is a sense of tight- 
ness and choking about the pharynx, attended by a hesitation in swallowing, 
especially of liquids. In one of my cases this early disturbance of the func- 
tion of the muscles of deglutition made it possible for me to recognize the 
disease a few hours after the attack commenced. The patient was a sailor, 
about 30 years of age, who sent for me to treat him for a supposed cold. 
The only thing he complained of was a sense of constriction in the throat 
and difficulty in swallowing. In examining the cavity of the mouth and 
pharynx for evidences which would explain the existing symptoms I found a 
profuse salivary secretion; the mucous membrane of the pharynx was con- 
gested, but no signs of deep-seated inflammation could be found in the re- 
gion of the tonsils. My suspicions were awakened at once. I ascertained 
that six weeks before a small pet dog owned by the family had died after a 
few days of illness, and that one day during this time, when the patient was 
lving on his back on the floor, the do.o- had licked a small sore on the ante- 



SYMPTOMS AM) DIAGNOSIS. 465 

rior surface of the lobe of the left ear. Requesting the patient to drink water 
from a glass which I handed him, I noticed a hesitation on his part to com- 
ply with my wish; but finally he grasped the glass with both hands, which 
trembled considerably, and, after waiting for the proper moment to come, 
applied it rapidly to his lips and made a desperate, but futile, effort to swal- 
low: the attempt was repeated several times, but only a very small amount 
was swallowed. The next group of muscles to become affected with con- 
vulsive spasms are the muscles of respiration about the larynx. The symp- 
toms of a well-developed case of hydrophobia are so well depicted by Flem- 
ing that I will give his own description: "The difficulty in swallowing 
rapidly increases, and it is not long before the act becomes impossible, un- 
less it is attempted with determination, though even then it excites the most 
painful spasms in the back of the throat, with other indescribable sensations, 
all of which appall the patient and cause him to dread the very thought of 
liquids. Singular nervous paroxysms or tremblings become manifest, and 
sensations of stricture and oppression are felt about the throat and chest. 
The breathing is painful and embarrassed, and interrupted with frequent 
sighs or a peculiar kind of sobbing movement, or catching of the breath; 
there is a sensation of impending suffocation and of necessity for fresh air. 
Indeed, the most marked symptoms consist in a horribly-violent convulsion 
or spasm of the muscles of the larynx and pharynx, or gullet, by which swal- 
lowing is prevented, and at the same time the entrance of air into the wind- 
pipe is greatly retarded. Shuddering tremors, sometimes amounting to gen- 
eral convulsions, run through the whole frame, and a fearful expression of 
anxiety, terror, and despair is depicted on the countenance/' 

Frothing at the mouth is rarely observed, but the viscid, tenacious mu- 
cus in the fauces and the profuse salivary secretion are frequently forcibly 
ejected by hawking and spitting. Shortly before death the patient's mouth 
is often full of this mucus or froth, which in some cases is tinged with blood. 
The pulse at first is not much changed in force and frequency, but as the 
disease advances it becomes feeble and rapid, and often intermittent. The 
temperature is always increased. In both of my cases the thermometer reg- 
istered from 101° to 103° F. at different times in the axilla. A post-mortem 
temperature of 106.2° F., taken in the rectum immediately after death, has 
been recorded. 

Occasionally the patient has hallucinations of sight and hearing, but 
usually the mental faculties are not much impaired. One patient, alluded 
to by Trousseau, heard the ringing of bells, and some mice run about on his 
bed. To the by-stander the most distressing phenomenon presented by hy- 
drophobic patients is the fear of impending death, which is usually mani- 
fested soon after the attack, and remains throughout the whole course of the 
disease. Xo kinds of assurances or consolations are able to dispel it. Death 



466 PKINCIPLES OF SUKGEKY. 

occurs from complete exhaustion, in most cases attended by well-marked 
evidences of asphyxia from spasm of the glottis; sometimes a convulsion 
is the final symptom, as in tetanus. 

The differential diagnosis between hydrophobia and tetanus is not al- 
ways easy. In both diseases the stage of incubation is variable, and both are 
characterized by excessive excitability of the cerebro-spinal centre, as is 'evi- 
dent from the muscular spasms and great hypersesthesia of the entire surface 
of the body during the stage of irritation. In hydrophobia infection always 
takes place from the bite of a rabid animal, and the difficulty in swallowing 
is caused by spasm of the pharyngeal muscles, and not by tonic contraction 
of the muscles of mastication, notably the masseters, as is the case in tetanus. 
In tetanus respiration is impaired by rigidity of the respiratory muscles of 
the chest; in hydrophobia by spasmodic contractions of the respiratory mus- 
cles of the larynx. Acute softening of the brain, and meningitis affecting 
the base of the brain and upper portion of the spinal cord, may give rise to 
symptoms that bear a faint resemblance to the clinical picture of hydro- 
phobia, but a careful study of the symptoms, individually and collectively, 
will disclose the real nature of the case under consideration. A purely neu- 
rotic affection has been described as lyssa nervosa falsa, which, it has been 
said, resembles genuine hydrophobia closely. Such cases are undoubtedly 
one of the manifold manifestations of hysteria; and, if so, it can be differ- 
entiated from true hydrophobia by the absence of fever and by the fact that 
the muscular spasms are not limited to the muscles of deglutition and the 
muscles of the larynx. Trousseau speaks of lyssa nervosa falsa as a mental 
hydrophobia. Fayrer describes a case of this kind in a young Scotchman in 
India, and Bollinger quotes a case of a boy who was twice frightened into 
simulated hydrophobia. 

In making a positive final diagnosis of hydrophobia it is necessary to 
establish, in the first place, the fact that infection occurred from a rabid 
animal within eight months from the development of the disease; and, in 
the second place, it is necessary to prove the existence of spasms of the mus- 
cles of deglutition in attempts to swallow liquids; and if at the same time 
spasms of the muscles of the larynx interfere with the function of respira- 
tion, all doubt as to the nature of the difficulty has been removed. 

PKOGNOSIS. 

If any doubt existed as to the nature of the case during life, an early 
fatal termination will corroborate the suspicions that may have been enter- 
tained. Decroix reports 9 cases of spontaneous recovery in dogs. In man 
this terrible disease is invariably fatal; there is no authentic instance on record 
of recovery from genuine hydrophobia. Death results unexpectedly, suddenly, 
or from apoplexy, asphyxia, or exhaustion, in from twelve hours to six days 



P \ DHOLOGl AND MORBID ANATOMY. 



467 



from the appearance of the first symptoms. The mean duration of the dis- 
ease is about four davs. One of my patients died on the fourth and the other 
on the fifth day after the attack. In 90 cases collected by Bouley, death oc- 
curred in 74 during the first four days, the largest proportion of these being 
on the second and third days. In only 16 was life prolonged beyond the 
fourth day. 

PATHOLOGY AND MORBID ANATOMY. 

Hydrophobia, like tetanus, to which disease it is so closely allied in 
many respects, is characterized by the absence of gross pathological changes 




Fig. 160. — A Blood-vessel from Medulla Oblongata in a Case of Hydrophobia. Large 
numbers of round cells are seen in its sheath. X 350. (Goates.) 



in the nervous centres and at the primary seat of infection. The scar which 
marks the wound or lesions through which infection occurred may be red 
and slightly swollen, but these changes are not present in all cases. Hydro- 
phobia is a disease in which there is every indication of irritation of certain 
nerve-centres and of a greatly-increased reflex irritability. The centres irri- 
tated here are less those of the cerebral hemispheres than of the spinal cord 
and medulla oblongata. The symptoms point mainly to the medulla ob- 
longata, and after death well-defined vascular lesions can be detected in this 
structure by means of the microscope. 

Similar lesions, but less marked, can be found in the spinal cord, and 



-JL6S 



PRINCIPLES OF SURGERY. 



still to a lesser degree in the other parts of the nervous system. The most 
prominent condition is an accumulation of leucocytes around the vessels in 
the substance of the cord and medulla oblongata (Fig. 160 >. Where the local 
lesion is most advanced the vessels are surrounded by several layers of leu- 
cocytes, which would indicate that the microbe of hydrophobia or its toxins 
produce an alteration of the capillary wall of sufficient intensity to entitle 
the process to be called inflammation. An increase of leucocytes is evident 
everywhere, so much so that the collections which can be found in different 
parts have been called miliary abscesses. As the leucocytes show no evi- 
dences of even approaching transformation into pus-corpuscles, these aggre- 
gations of leucocytes do not deserve the name of abscesses. Klebs is of the 
opinion that the microbe of hydrophobia does not enter the circulation di- 
rectly, but invades in preference the lymphatic vessels, as he found general 




Fig. 161.— From the Salivary Gland in a Case of Hydrophobia. In the middle is the 
portion of a duct; abundant round cells abound it as well as the glandular structures 

shown in outline. X :: 



lymphatic engorgement in a recent case. The same author also discovered. 
particularly in the submaxillary gland, deposits of finely granular, strongly 
refractive corpuscles of a faint, brownish color, closely packed together in 
clusters and rows, which he regards as possibly the vehicles for the trans- 
portation of the specific virus. Well-marked evidences of lev : sytes have 
been found by many in the salivary glands. 

There is hyperemia and cedenia of the substance of the brain, medulla 
oblongata, and cord, and of their membranes; deep-red injection of the 
mucous membrane of the pharynx and epiglottis, and sometimes recent 
swelling of the tonsils, follicular glands of the tongue, pharvngeal follicles. 
and of the lymphatic glands in the neighborhood of the jaw. The stomach 
and intestines show decided injection, and often hemorrhagic extravasations. 
The lungs are charged with blood, with frequent points of capillarv hsemor- 



ti;i:atmi:\ i . 4G9 

rhage. and sometimes emphysema as a result of the dyspnoea. In the kid- 
also, there are signs of irritation in the form of dilatation of vessels and 
haemorrhage. According to Bollinger, the anatomical picture bears the 
strongest resemblance to that seen in cases of death from asphyxia or thirst. 
The conditions found, post-mortem, furnish an illustration that here an in- 
tense irritant is circulating in the blood, and the intensity of it may be 
judged from the fact that all these very marked appearances, although nearly 
all of them recognized only by the use of the microscope, occur in the short 
space of three or four clays. 

Tscherniseheff has made a careful study of the microscopical morbid 
anatomy of hydrophobia in man based upon a fatal case. In the dorsal and 
lumbar regions of the cord he found intense hyperemia in the white and 
gray substances, with an infiltration of the perivascular lymph-spaces by 
lymphoid cells. Black agglomerations were found at the periphery of the 
white substance and pigmentary degeneration of the cells in Clarke's col- 
umns. Xumerous cells of the anterior horns of Clarke's columns appeared 
deformed and altered, presenting chromatolysis. The nuclei were displaced 
peripherally and deprived of their envelopes, and sometimes more intensely 
stained than the cell-body. In some cells the processes were detached. All 
these changes were most marked in the cervical portion of the cord. Small 
extravasations of blood were found in the floor of the fourth ventricle. The 
pathological changes were less pronounced in the cortex of the brain, the 
basal ganglia, the cerebellum, and isthmus. 

TKEATMEXT. 

As hydrophobia is an absolutely-fatal disease, the treatment resolves 
itself into prophylactic measures to prevent the disease, and means of pal- 
liation after it has developed. 

Prophylactic Treatment. — The most effective prophylactic measures 
consist in preventing the spread of the disease, among animals, by the kill- 
ing or strict isolation of animals which present symptoms of rabies. If 
animals which are suspected of being rabid are known to have bitten per- 
sons, they should not be killed at once, but should be kept in close confine- 
ment unknown to the injured person, until, by observation or the course of 
the disease, a positive diagnosis can be made. As soon as a positive diagnosis 
of rabies can be made, then the animal should be killed to prevent any 
further possibility of infecting other animals or persons. If a person is 
bitten by an animal which presents suspicious symptoms, no time should be 
lost to prevent infection by removing or destroying the virus. 

(a) Excision of Wound. — As the virus of hydrophobia appears to be 
slowly diffused in the tissues, thorough local treatment of the wound may 
prove successful in preventing infection, even if resorted to several hours or 



470 PRINCIPLES OF SURGERY. 

days after inoculation has occurred. As soon as possible after the bite has 
been inflicted, a constrictor should be applied on the proximal side of the 
wound and medical aid summoned without delay. In the meantime an at- 
tempt should be made to remove the virus from the wound by suction. In 
recent cases the simplest and safest treatment consists in excising the tissues 
in the immediate vicinity of the puncture, and after thorough disinfection 
in closing the wound with sutures. 

(b) Cauterization of Wound. — The same object is accomplished, but 
with a lesser degree of certainty, by cauterization. The most efficient caustic 
is the actual cautery. With the knife-point of a Paquelin cautery the wound 
is deeply cauterized, and the resulting eschar is protected against infection 
with pus-microbes by an antiseptic dressing. Of the chemical caustics the 
most valuable are caustic potassa, nitric acid, sulphuric acid, and nitrate of 
silver, their efficiency being estimated in the order named. The authority 
for excision and thorough cauterization, as prophylactic measures, is to be 
found in the fact that, of 134 collected cases, in which bites of mad dogs 
were cauterized, 68 escaped and 42 died: a degree of immunity far above the 
average, which is 33 per cent. (Bouley). 

(c) Prophylactic Inoculations. — Pasteur has shown, by a long series of 
inoculations, made first in monkeys, rabbits, and guinea-pigs, and later ex- 
clusively in rabbits, that if the virus of hydrophobia is introduced into the 
brain of these animals the disease is invariably produced after a fixed period 
of incubation. As the period of incubation in successive inoculations in the 
same animal is shortened, we must take it for granted that the virulence of 
the material is increased. In the rabbit the first inoculation under the dura 
mater is followed by a period of incubation of fourteen days' duration, 
which, in successive inoculations in the same animal, is reduced to seven 
days. Spinal inoculations in dogs produce in these animals fatal rabies in 
the same length of time. Pasteur made an additional important discovery, 
as he found that the spinal cord of the inoculated rabbits, increased in 
virulence by successive inoculations, is again diminished in its virulence 
by preserving it in dry air, guarding at the same time against contami- 
nation with other microorganisms. This discovery led to a method by 
which the virulent action of such preparations can be accurately graded, 
inasmuch as the action of the spinal cord, in the drying-room, in 7 to 8 days 
is reduced from its highest degree of virulence to nil. By using the spinal 
cord of rabbits treated in this manner in different strengths, at first weak 
and then gradually stronger preparations, it was found possible to render 
animals immune to the action of inoculation material of the highest potency. 
By this method Pasteur succeeded in creating absolute immunity against the 
strongest hydrophobic virus in 50 dogs. The success of these prophylactic 
inoculations in animals enabled Pasteur to resort to the same method of 



THE AT. Mil NT. 



471 



treatment in persons bitten by rabid animals, as the long stage of incubation 
made it possible to carry out this treatment before the actual development 
of the disease was expected. The first human being subjected to this treat- 
ment was on July 5, 1885, and from that time until the close of the year 
1889 2682 persons bitten by rabid animals, or animals that were suspected 
of being mad, with the result that of this large number only 31 died, equiv- 
alent to 1.15 per cent., while the general mortality in persons under similar 
circumstances without such prophylactic inoculations has been at least 16 
per cent. The danger is always greatest when the bite is inflicted by rabid 
wolves. Pasteur collected 100 cases of persons bitten by rabid wolves, and 
of this number not less than 82 died. Pasteur had an opportunity to submit 
to his treatment 38 persons bitten by rabid wolves, and of this number only 
3 died: a mortality of 7.89 per cent. 

The following tables represent Pasteur's work for four years: — 





Table 


A. 


Table 


B. 


Table 


O. 


Total. 


Years. 


B«d 






g-d 






%i 




4J 4J 


Wr— ' 




>*"? 

."£+= 








11 






3§ 


i-S 




03 0) 


S° o3 


£ 








A 


3* 







■2* 


52 


A 


|| 


5£ 


P 


II 


1886 .... 


231 


3 


1.30 ' 


1926 


19 


0.99 


514 


3 


0.58 


2671 


25 


0.94 


1H87 .... 


357 


2 


0.56 


1156 


10 


0.86 


257 


1 


0.39 


1770 


13 


0.73 


18*8 .... 


402 


« 


1.49 


972 


2 


0.21 


248 1 


0.40 


1622 


9 


0.55 


1889 . . . . ! 


346 


2 


0.58 • 


1187 


2 


0.17 


297 


^ 


0.67 


1830 


6 0.33 


Total . . . ; 

1 


1336 : 13 


0.97 ! 


5241 


33 


0.63 


1316 


7 


0.52 


7893 


53 0.67 

I 



The bites have been divided into three categories, — (1) those of the head 
and face; (2) those of the hands; (3) those of the limbs and trunk, — with 
the following result: — 



1. Head and face . 

2. Hands 

3. Limbs and trunk 



Tables A and B. 







>>'7 


II 


-3 




It 




£ o 


A 


3® 








503 


14 


2.36 


376S 


26 


0.69 


2216 


6 


0.27 




,n 





057 



46 | 0.70 



Table C. 



o» 






619 
618 



1316 



o <* 

S P. 



127 

0.48 
0.48 



0.53 



Total. 



672 
4387 
2834 



53 



2.23 
0.66 
0.32 



0.67 



Table A comprises those persons bitten by animals determined to be 
rabid by experiments in rabbits, made in the laboratory, or by the death of 
other animals or persons bitten by the same animal. 



472 PRINCIPLES OF SURGERY. 

Table B comprises those persons bitten by animals demonstrated to be 
rabid by the examination of a veterinary surgeon, or by the clinical signs 
shown during life. 

Table C comprises those persons bitten by animals suspected to be 
rabid. 

Gibier has treated 610 persons having been bitten by dogs or cats since 
the New York Pasteur Institute was opened until October 15, 1890. For 
480 of these persons it was demonstrated that the animals which attacked 
them were not mad. Consequently the patients were sent back after having 
had their wounds attended, during the proper length of time, when it was 
necessary. In 130 cases the antihydrophobic treatment was applied, hydro- 
phobia having been demonstrated by veterinary examination of the animals 
which inflicted the bites, or by the inoculations in the laboratory', and in 
many cases by the death of some other persons bitten by the same animal. 
All these persons were fully protected by the prophylactic inoculations. 

Protopopoff (C entralblatt fur Chirurgie, October 18, 1890) has made 
some experiments which tend to prove that Pasteur's prophylactic inocula- 
tions accomplish their object by the presence of a fixed virus, and not from 
the action of the microbe of hydrophobia. He took the spinal cords of 
animals which had died of rabies and removed from them the fixed virus by 
sterilization. He found that placing such cords in glycerin bouillon at a 
temperature of from 65° to 68° F. for from fifteen to twenty days accom- 
plished this purpose, and that an emulsion prepared with spinal cords treated 
in this way can be used as a sterilized culture of the virus. A series of ex- 
periments and control experiments by the same author showed that immu- 
nity against experimental rabies could be secured by inoculating animals 
with the non-poisonous emulsion just described. Out of 19 dogs protected 
by inoculations with the sterilized virus, 14 were protected against the effects 
of Pasteur's virus, while every one of the 14 animals used for control experi- 
ments died. 

Kraiouchkine states that, in the year 1895, 269 persons were treated in 
St. Petersburg for hydrophobia by Pasteur's method. In two cases the dis- 
ease developed before the treatment was completed, another patient died 
after the treatment, giving a mortality of 0.4 per cent. Lagorio, of the 
Chicago Pasteur Institute, gives the result of his work since 1890, to date, 
May 1, 1900:— 

To date, a grand total of 950 patients received the antihydrophobic 
treatment. 

Eight hundred and fifty-five persons were bitten by dogs, 31 by cats, 
35 by horses, 11 by skunks, 5 by wolves, 4 by cows, 2 by calves, 1 by a rat, 
1 by a mule, 1 by a pig, and 4 by hydrophobic human beings. Four hun- 
dred and sixty-two persons received severe and multiple lacerated bites on 



ti;i:at.\m:\ i . 473 

the hands and wrists, KM on the head and face, 134 on the arms, 204 on the 
legs and thighs, and 29 on the trunk. 

Following the role of Past our. the patients treated have been classified 
as follows: First: Persons bitten by animals recognized and ascertained to 
be rabid by the test experiment made in the laboratory or by the death of 
other persons or animals bitten by the same animal. Of this class, 368 were 
treated. Second: Persons bitten by animals recognized to be rabid by the 
symptoms of the disease shown during life. Of this class, 420 were treated. 
Third: Persons bitten by animals strongly suspected to be rabid. Of this 
class, 162 were treated. 

Only 5 deaths have been reported, thus giving a mortality of 0.52 per 
cent.: a result which we consider marvelous when accurate statistics tell us 
that, before the discovery of the Pasteur treatment, the mortality was as high 
as 88 per cent, for the bites of the face, 67 per cent, for bites of the hands, 
and 20 to 30 per cent, for the bites of the limbs and trunk. 

Three patients were overtaken with hydrophobia at the Institute while 
under treatment. This was due to the lateness o£ their coming, many days 
having passed since they were bitten. Hence, we cannot urge too strongly 
the necessity for applying for treatment at once after being bitten. The 
sooner the better. Every day that passes shortens the period of incubation 
and also the chances of successful results. 

All patients tolerated the treatment perfectly well. It being absolutely 
harmless, it can be taken with confidence and without fear of injury to the 
health. The treatment consists in hypodermic injections of a specially-pre- 
pared virus of different gradation of strengths for a period of fifteen days, 
eighteen days, or twenty-one days, according to the severity of the case. The 
method used is identical with that used in Paris. 

These results must convince the most skeptical of the practical utility 
of Pasteur's prophylactic treatment against hydrophobia, and, although the 
method will not be perfect until the microbe of this disease is discovered and 
mitigated (pure cultures are employed), this crude method must be viewed 
as a great boon to a class of patients otherwise exposed to the risks of con- 
tracting the most terrible and hopeless of all diseases. Pasteur institutes 
have sprung up in different parts of the civilized world, and the accumulated 
experience of all those engaged in this kind of work bears strong testimony 
in favor of the prophylactic inoculations against hydrophobia as taught and 
practiced by Pasteur. At the bacteriological laboratory in Cuba 306 persons 
have been treated by the "double intensive" plan. Of these, only 2 died after 
going through the full course: a mortality of 1.63 per cent. All these cases 
were bitten by dogs proved experimentally and clinically to be rabid, or, at 
any rate, suspected. That the inoculations were conducted with due con- 
servatism is indicated by the fact that only 306 persons were treated out of 



474 PRINCIPLES OF SURGERY. 

700 applicants. Some of the failures Pasteur attributes to the long intervals 
between the prophylactic inoculations, and in grave cases he now advises that 
successive inoculations should be made with cord-substance twelve, ten, and 
eight days old, during the first twenty-four hours; on the second day with 
material six, four, and two days old; on the eighth day with material one day 
old, to be followed by two similar series of inoculations. By following this 
energetic plan of prophylactic treatment he has been able to secure protection 
even in the most urgent cases; that is, in cases where the stage of incubation 
had nearly terminated. 

Palliative Treatment. — The nature of the disease should, under no cir- 
cumstances, be disclosed to the patient, as the people, high and low, educated 
and ignorant, are only too familiar with the terrible suffering caused by this 
affection, and its absolute certainty of a fatal termination in a few days. In 
one of my cases the patient had been made acquainted with the character of 
the ailment, and begged piteously that his life might be terminated by the 
administration of chloroform, knowing well that the intense suffering would 
continue to the last moment. As light, draughts of air, and noise of every 
kind increase the suffering by exaggerating convulsive spasms, these aggra- 
vating causes should be eliminated from the patient's room, and only a lim- 
ited number of persons should be admitted to render the necessary assistance 
and carry out the directions of the attending physicians. As the saliva of 
hydrophobic patients contains the specific virus, those placed in charge of 
the patient should protect themselves against inoculation by preventing the 
contact of the saliva with abraded surfaces, or, still better, by covering any 
abrasions which may exist with a collodium dressing. Thirst is quenched 
by administering water per rectum. Medicines by the mouth should not be 
given, as every attempt at swallowing brings on violent spasms of the mus- 
cles of deglutition and the respiratory muscles of the larynx. Morphia com- 
bined with small doses of atropia should be given subcutaneously in such 
doses and at such intervals as will procure rest. The subcutaneous admin- 
istration of quinine and woorara has been advised, but both of these remedies 
are more harmful than useful, and neither of them adds anything to the 
duration of life or alleviation of suffering. The only remedy which can be 
relied upon to afford prompt relief is chloroform by inhalation. Ether 
should never be used, as the hyperaemic condition of the brain and spinal 
cord which is present in every case of hydrophobia sufficiently contraindi- 
cates it. The inhalation of chloroform must be conducted by an assistant or 
a competent, reliable nurse, and should never be carried be} 7 ond the point 
where relief is afforded, and it should be repeated as often as the paroxysms 
return. 



CHAPTER XIX. 

Surgical Tuberculosis. 

Tubercular lesions furnish a most excellent illustration, clinically and 
under the microscope, of the origin, course, termination, and tissue-changes 
of what is known as chronic inflammation. A histological description of a 
tubercular nodule is a description of the pathology of chronic inflammation. 
Tuberculosis in all its forms is caused by a specific microbe the action of 
which upon the tissues produces histological and vascular changes which are 
characteristic of chronic inflammation. Of all the microbic diseases, with 
the exception of suppuration, tuberculosis is of the greatest interest and im- 
portance to the surgeon. Of the greatest interest because the tubercular 
lesions which come under his care are more clearly understood from a bac- 
teriological stand-point than most of the other surgical diseases, and of the 
greatest importance on account of their great frequency. That large class of 
ill-defined lesions which were grouped under that indefinite and vague term 
scrofula, in the text-books of but a few years ago, have been shown by recent 
research to be identical with the recognized forms of tuberculosis, etiolog- 
ically, clinically, and anatomically. In this chapter I shall aim to give a 
brief description, from a bacteriological and clinical stand-point, of such 
localized tubercular lesions which, by general consent, are regarded as sur- 
gical affections and requiring surgical procedures in their successful treat- 
ment. 

HISTORY OF THE 3IICROBIC ORIGIN OF TUBERCULOSIS. 

The first inoculation experiments with tubercular products were made 
by Kortum in 1789 and Cruveilhier in 1826. In 1834 Erdt succeeded in 
producing numerous nodules in the lungs of horses by inoculating them with 
tubercular pus, and Klencke, in 1843, produced tuberculosis in rabbits by 
intravenous injections of tubercular matter. The results obtained from the 
crude inoculation experiments which were made years ago by Yillemin 
pointed strongly toward the infectiousness of tuberculosis. Yillemin's ex- 
periments consisted in the subcutaneous insertion, behind the ear of rab- 
bits, of fragments of tubercular tissue, or fluid taken from the cavity of a 
tubercular lung, recently removed from patients who had died of pulmonary 
phthisis. The first animal thus infected was killed three and a half months 
after inoculation. The lungs and most of the internal organs were found 
diffusely infiltrated with miliary tubercle. His numerous later experiments 
vielded similar results and led him to the following conclusions: "Phthisis 
of the lungs (like tubercular diseases in general) is a specific infection. Its 

(475) 



476 PRINCIPLES OF SURGERY. 

etiology depends on an inoculable agent. It can be readily communicated 
from man to animal by inoculation." 

Vogel repeated the experiments of Yillemin on horses without success. 
Biffi, Yerga, and Sangalli experimented on mules, cows, sheep, dogs, cats, 
mice, and chickens, with negative results. The experiments of Langhans led 
him to the conclusion that tubercle could not be communicated in the man- 
ner described by Yillemin. He claimed that the inoculation material acted 
only the part of a foreign body, the inflammation following its insertion into 
the tissues differing in no way from the ordinary forms of inflammation. 
Among those who made successful inoculation experiments, and adopted the 
doctrines advanced by Yillemin, may be mentioned Hevard and Cornil, 
Hoffmann, Cohn, Behier, Empis, Mantegazza, Bizzozero, Lebert and AVyss, 
Klebs, Koester, Waldenburg, Bijuen, Simon, Sanderson, W. Fox, Papillon, 
Mcol, and Laveran. Hevard and Cornil were able to propagate tuberculosis 
by inoculations with crude tubercular material. They inoculated with gen- 
uine tubercular material, but faile'd with cheesy products. Marcet inoculated 
11 guinea-pigs with the sputa of phthisical patients, and in 10 of them the 
experiment proved successful. Cohnheim injected tubercular material into 
the anterior chamber of the eye in rabbits, and succeeded in producing the 
disease artificially in this manner. Hueter produced tuberculosis of the iris 
by inserting into the anterior chamber of the eye in rabbits fragments of 
tubercular tissue. Toussaint showed that true tubercle, both in man and 
animals, reproduces itself indefinitely with absolutely constant and identical 
properties, and that it is quite capable of being transmitted from animal to 
animal without losing its virulence. 

Krishaber and Dieulafoy experimented on monkeys, and the results 
obtained led to the conclusions: 1. That human tubercle, when inoculated, 
kills a monkey in nine out of ten cases, with lesions analogous to those met 
in man. 2. The effect of the inoculation varies according to the substance 
employed; the gray granulation is most, and the pulmonary parenchyma 
least, infectious. Schtiller and Lentz made successful inoculations with 
blood taken from tubercular rabbits. Lippl, Schweninger, Tappeiner, and 
Weichselbaum succeeded in producing the disease in animals by inhalation. 
Successful feeding experiments were made by Chaveau, Aufrecht, and Bol- 
linger. 

Since Yillemin announced the inoculability of tuberculosis diligent 
search was made to discover and isolate a specific microorganism which 
should be characteristic of this disease. The first cultivation experiments 
were made by Klebs in 1877. He found, by examining fresh specimens of 
tubercle of human beings, that they invariably contained bacteria. He culti- 
vated them in egg-albumen and Bergmann's culture fluid, and found, by 
experiment, that the cultures produced the same effect in causing disease 



EISTOBl OF THE KICBOBIC ORIGIN OF TUBERCULOSIS. L7V 

by inoculation as the tissues from which they wore grown. Injections of 
the culture under the skin, into the muscles, lungs, pleural and peritoneal 
cavities, caused death of the animals from tuberculosis. Cultures made in 
a similar manner from scrofulous glands and lupous tissue produced the 
same effect in animals. Max Schuller repeated the experiments of Klebs 
with the same results. He described the specific microbe as round and rod- 
shaped bacteria, the rods bulbous at both ends, composed of two, seldom 
more, spherical bodies. He found these microbes in great abundance in tu- 
bercular joints and tubercular foci in bone. He produced the disease arti- 
tlcially in animals which were previously inoculated by making contusions 
of joints. Other workers in the same field advanced theories, found and de- 
scribed microbes which were supposed to bear a direct etiological relation- 
ship to tuberculosis, but nothing definite was known on the subject until 
the founder of modern bacteriology, Eobert Koch, in 1882, announced to the 
profession his great discovery. He had found and demonstrated the true 
and essential cause of tuberculosis, the bacillus of tuberculosis, and, in his 
first publication, brought such convincing proof of the correctness of his 
claim that, with few exceptions, it brought conviction even to the minds of 
the most skeptical. He had not only found the bacillus, but showed that it 
was present in all tubercular lesions. He had isolated and cultivated the 
bacillus from tubercular tissue; and, finally, he had furnished the crucial 
test: had produced tuberculosis, artificially, in animals by inoculation with 
pure cultures. 

A number of pathologists who inoculated animals with non-tubercular 
material claimed that they had produced pathological conditions analogous 
to those found in animals which had been infected with the virus of tuber- 
culosis. Fragments of sponge implanted in the abdominal cavity produce a 
condition which resembles tubercular inflammation, and it has been asserted 
that powdered glass has a similar property. Schottelius, Wargunin, Weich- 
selbaum, and Martin have employed various substances by way of experi- 
ment, such as powdered cheese, brain-substance, lycopodium-seed, Cayenne 
pepper, and pulverized cantharides. They caused these to be inhaled in the 
form of a fine spray, with the result that they were almost invariably able to 
produce, in different animals, an eruption of nodules in the lung and some- 
times in other organs. With Limburger cheese Weichselbaum produced an 
eruption in the lungs and kidneys of dogs, after fifteen inhalations during 
seventeen days, which, histologically, could not be distinguished from the 
products of genuine tuberculosis. Further experimentation soon showed 
that these were instances of pseudotuberculosis; that, while the gross ap- 
pearances of the lesions resembled true tuberculosis, inoculations with this 
material never reproduced the disease, while inoculations with tubercular 
tissue could be clone through a series of animals without impairing the 



478 PRINCIPLES OF SURGERY. 

potency of the virus or varying the constancy of the results. Koch's dis- 
covery did not lead to such energetic search for the bacillus of tuberculosis 
among surgeons as physicians, because, as Konig asserts, the symptoms and 
signs of the tubercular affections coming under the observation of surgeons 
are so characteristic that, for practical purposes, a correct diagnosis could be 
made in the majority of cases without a knowledge of their microbic nature 
and the improved methods for making a positive diagnosis derived there- 
from. Koch himself, in the publication above referred to, demonstrated the 
presence of the bacillus in lupus, the so-called scrofulous glands, tubercular 
joints, etc. He called attention to the fact that in these affections the ba- 
cillus can be constantly found in giant cells and between the epithelioid 
cells, while it is more difficult to find it in cheesy products unless caseation 
has taken place quite rapidly. 

Koch examined 19 cases of miliary tuberculosis, in which bacilli were 
found in every nod ale; 29 cases of phthisis, in every one of which bacilli 
were found most numerous, with the exception of the sputum, in recent 
caseous foci and in the walls of cavities undergoing speedy destruction. He 
also found them constantly in tubercular ulcers of the tongue, tubercular 
pyelonephritis, and tuberculosis of the uterus and testicles; also in 21 cases 
of tuberculosis of lymphatic glands. Further, in 13 cases of tuberculosis 
of joints and in 10 cases of tuberculosis of bone; in 4 cases of lupus, in which 
only a single bacillus could be seen in the giant cells; in 17 cases of Perl- 
sucht in cattle. Finally, in animals inoculated with tubercular virus: 273 
guinea-pigs, 105 rabbits, 44 field-mice, 28 white mice, 19 rats, 13 cats, be- 
sides dogs, chickens, pigeons, etc. Examinations of sputa and organs in 
various other non-tubercular affections for bacilli resulted, without excep- 
tion, negatively. 

"Weichselbaum, Meisels, and Lustig found tubercle bacilli in the blood 
in cases of acute miliary tuberculosis, both during life and after death. 
Schuchardt and Krause examined 40 cases of tuberculosis of bones, joints, 
tendon-sheaths, and the skin in Volkmann's clinic, and never failed in find- 
ing bacilli, although in some specimens careful and prolonged search had 
to be made. 

Schlegtendal examined 520 specimens of pus from tubercular suppura- 
tions, and found bacilli present in about 75 per cent, of the cases. Mogling 
found the bacillus never absent in tubercular pus from 53 patients. The 
literature on the etiological relation existing between the bacillus of tuber- 
culosis and the affections of the skin, glands, bones, and joints, which have 
heretofore been grouped under the head of scrofula, is immense; but the 
foregoing quotations will suffice to show the regularity with which the ba- 
cillus can be found in the tissues of the so-called scrofulous affections, as 
well as in all recognized clinical forms of tuberculosis. 



A 



Fig. 162.— Tubercle Bacilli containing Spores. (Zeiss 1 / 18l 0.4.) (R. Koch.) 



/ 






... C 



\\ 



: 



, 



Fig. 163. — Tubercle Bacilli from a Tubercular Cavity. (Carbol-fuchsin, nitric acid, 
methyl-blue. Zeiss Vis, 0.4.) 



RIPTION OF BACILLUS TUBERCULOSIS. 479 



DESCRIPTION" OF BACILLUS TUBERCULOSIS. 

The tubercle bacillus, with the exception of the bacillus of septicaemia 
in mice, is the smallest of the known bacilli. The length of each rod varies 
from one-fourth to three-fourths of the diameter of a red blood-corpuscle. 
The thickness corresponds to that of the bacillus of sepsis in mice. The rods 
are either straight or, what is more common, bent or curved near the centre. 

In cultures and in the tissues they occur singly, in pairs, or in bundles. 
In a state of fructification the bacilli contain from two to six spores. In 
stained rods the spores appear as clear, minute, ovate spaces, as they are not 
affected by the coloring material. In some bacilli the spores form slight pro- 
jections on the sides of the rod. Eeproduction by spore-formation also takes 
place in the tissues within the animal body. In badly-stained specimens, and 
on superficial examination, the spores impart to the bacillus the appearance 
of a chain coccus; but, examined closely, it is seen that the protoplasm of 
the bacillus is continuous, and the apparent interruptions are due to the 
presence of the spores. The bacilli of tuberculosis are non-motile, and con- 
sequently possess no power of locomotion, and cannot penetrate into the 
tissues without assistance. In the tissues they are found in the interior of 
giant cells and within and between epithelioid cells. They are constantly 
found in places where the tubercular process is commencing or actively 
progressing. In the beginning they are isolated and in the interior of cells; 
later, they become more abundant and form groups. In cheesy deposits they 
are either entirely absent or few in number. The virulence of caseous mate- 
rial is due mostly to the presence of spores, which may remain in a latent 
condition and yet retain their power of reproduction under more favorable 
conditions for an indefinite period of time. As soon as giant cells appear, 
they contain bacilli in their interior, as a rule. In some giant cells only one 
bacillus can be found, and then it occupies a part of the cell which contains 
no nuclei. 

In giant cells with numerous bacilli the latter arrange themselves 
around the periphery in the interior of the cell, while the centre contains 
few or none. 

The first ingress of bacilli into the diseased tissues probably takes place 
by wandering cells, which transport the non-motile microbe. In many 
inoculation experiments such bacilli-containing cells have been found in 
the blood and tissues. 

Staining. — The peculiar behavior of the bacillus of tuberculosis to dif- 
ferent staining material enabled Koch not only to discover this microbe, but 
also to differentiate it from all other microbes. While the aniline dyes and 
other nuclear staining material showed no microorganisms in tubercular 
products, the bacillus came plainly into view if a small quantity of alkali 



4S0 



PRINCIPLES OE SURGERY. 



were added to the aniline solution. Later experience proved that the same 
effect is produced if. instead of an alkali, aniline, toluidin, turpentine, car- 
bolic acid, or ammonia is added. All of these substances aid the penetration 
of the staining fluid into the bacillus. Of especial advantage is the discovery, 




Fig. 164. 



-Giant Cell with One Tubercle Bacillus. Sectioi 
700:1. (Fliigge.) 



from lupus of skin. 



also made by Koch, that the staining fluid is fixed more permanently by 
treating with nitric or muriatic acid the sections stained with alkaline ani- 
line dyes: a procedure which removes the staining from the cells, nuclei, and 
all other bacteria, while the tubercle bacillus alone remains stained. The 




Fig. 165.— Giant Cell (Miliary Tuberculosis). 700 : 1. (Fliigge.) 

preparation is further completed by staining once with one of the ordinary 
aniline dyes, which stains the cells and nuclei and other bacteria, so that the 
tubercle bacillus, for instance, appears red. the nuclei and other bacteria 
blue. 



\\ 



/ 



p 






\ 



^ 



y 



\ 



'/, ^ y S 






\ 



// 






Fig. 166. — Glass-Slide Preparation from the Tissue-juice of a Fresh Inoculation- 
tubercle. (Ehrlich's staining. Zeiss, homog. immers., 1 / J2 ', 0.4; magnified about 1500 
times.) (Baumgarten.) 






ft 




Fig. 167.— Giant Cell with Radiating Arrangement of Bacilli. From encysted bronchial 
glands in miliary tuberculosis. 700 diam. (Koch.) 




Fig. 168.— Tubercle Bacilli. Colony on solidified blood-serum, fourteen days old; 
stained with carbol-fuchsin, decolorized with dilute nitric acid. X 100. {Frankel and 
Pfeiffer.) 



DESCBIPTIOB 01 BACILLUS TUBERCULOSIS. 481 

Most of the bacilli (Fig. 162) contain spores, the majority of them 
slightly curved or bent; they lie free, — that is, outside the cells. Where 
they appeal to be within the cells, a close examination shows them to be 
either upon or underneath the cells. 

For section-staining Ehrliclvs method is the best: — 

Saturated alcoholic solution of methyl-violet or fuchsin 11 parts. 

Aniline water 100 parts. 

Absolute alcohol 10 parts. 

Sections are left for twelve hours in this solution. Treat the specimens 
with l-to-3 solutions of nitric acid a few seconds; wash in alcohol (60 per 
cent.) for a few minutes; after-stain with diluted solution of vesuvin or 
methylene-blue for a few minutes; wash again in 60-per-cent. alcohol; de- 
hydrate in absolute alcohol; clear with cedar-oil; mount in Canada balsam. 

Ziehl-Xeclson Method. — Leave the sections for fifteen minutes in carbol- 
fuchsin solution; decolorize in 25-per-cent. solution sulphuric or nitric acid; 
wash in 6-per-cent. alcohol; immerse in a saturated aqueous solution of 
methylene-blue for double stain; wash, dehydrate, and mount in balsam. 
The examination of fluids for bacilli can be done rapidly and most satis- 
factorily by Gibbes* method: — 

G1BBES' MAGENTA SOLUTION. 

Magenta 2 parts. 

Aniline oil 3 parts. 

Alcohol (specific gravity, 0.830) 20 parts. 

Distilled water 20 parts. 

Stain cover-glass preparations in this solution for fifteen or twenty min- 
utes; wash in l-to-3 solution of nitric acid until the color is removed; rinse 
in distilled water; after-stain with methylene-blue, methyl-green, iodine- 
green, or a watery solution of crysoidin, five minutes; wash in distilled water 
until no more color comes away; transfer to absolute alcohol for five min- 
utes; dry, and preserve in Canada balsam. 

M. Dorset recommends the staining of cover-glass preparations made 
in the usual way, for five or ten minutes in a cold, saturated solution of 
sudan iii in 80 per cent, of alcohol, and then to wash for five minutes in 
70-per-cent. alcohol. Tubercle bacilli stained in this manner are not de- 
colorized after remaining in 4-per-cent. solution of sulphuric, nitric, or hy- 
drochloric acid or ammonia. Sections (fixed in alcohol and imbedded in 
celloidin) may be stained in the same manner, and then counterstained with 
methylene-blue, dehydrated in absolute alcohol, and cleaned in oil of cloves. 
Smegma and other bacilli are not stained by this method. Presumably 
the procedure depends on the presence of fat in the tubercle bacilli; and 
the beaded appearance which is very marked in the sudan preparations, 
probably indicates the presence of fat-droplets in the bacilli. Sudan is a 
specific stain of fat. 

31 



482 



PRINCIPLES OF SURGERY. 



>>..,!* 



,i, 



Cultivation. — The best culture-medium for the bacillus of tuberculosis 
is solid, sterilized blood-serum of the cow or sheep, with or without the 
addition of gelatin, at a temperature of 37° to 38° C. (98.6° to 100.4° F.). 
The bacillus grows very slowly, and only between the temperatures of 30° 
and 41° C. (86° and 105.8° F.). In about a week or ten days the culture 
appears as little whitish or yellowish scales and grains. Cultivations can also 
be made in a glass capsule or solid blood-serum, 
and the appearance of the growth studied under the 
microscope. The scales or pellicles are then seen 
to be made up of colonies of a perfectly charac- 
teristic appearance. The growth ceases after three 
or four weeks. The blood-serum is not liquefied 
unless putrefactive bacteria contaminate the cult- 
ure. Frankel figures, in his "Atlas der Bacterien- 
kunde," a luxuriant culture of the bacillus of tuber- 
culosis upon glycerin-agar. 

Nocard and Eoux have found that coagulated 
blood-serum is improved for the growth of the ba- 
cillus by adding peptone, soda, and sugar. A 
further addition of 6 to 8 per cent, of glycerin 
favors the growth of the bacillus still more, while, 
at the same time, it prevents the formation of a 
dry crust upon the culture-medium, which other- 
wise forms by evaporation. They also made suc- 
cessful cultivations upon agar-agar bouillon, to 
which was added 6 to 8 per cent, of glycerin, kept 
at a temperature of 39° C. (102.2° F.). 

Koch has cultures 3 years old which have 
passed through 40 generations and still retain their 
virulence, showing plainly the longevity and te- 
nacity of the bacillus of tuberculosis. 



IRK 



INOCULATION EXPERIMENTS. 



Fig. 169. — Vegetations of 
Tubercle Bacilli upon Ster- 
ilized Blood-serum, Twenty 



Long before the discovery of the bacillus of 
sTx"~weeks oid. ' Natural tuberculosis by Koch genuine tuberculosis was 

Size. (Baumgarten.) / . . ° . . 

produced artificially m animals by inoculation 
with the products of tubercular inflammation. Hueter inoculated the 
anterior chamber of the eye in rabbits with lupous tissue, and produced 
typical tuberculosis of the iris. Schuller introduced fragments of lupous 
tissue directly into the veins of animals, and in this way caused pulmo- 
nary tuberculosis. Koch produced tuberculosis in animals susceptible to 
this disease by implantation of tubercular tissue in various localities and 



[N001 CATION EXPERIMENTS. 483 

by inoculation with pure cultures, the experiments yielding, almost with- 
out exception, positive results. The same author inoculated the anterior 
chamber of the eyes in 18 rabbits from 5 cases of lupus, and in all of them 
tuberculosis of the iris was produced, and, if life was prolonged for a 
sufficient length of time, was followed by tuberculosis of the lymphatic 
glands of the neck, lungs, kidneys, liver, and spleen. Similar results were 
also obtained in 5 guinea-pigs. Cornet has made numerous experiments, 
in Koch's laboratory, on animals, to ascertain the inoculability of tubercu- 
losis through abrasions of the skin, or a pure culture of tubercle bacilli 
was applied to a cutaneous abrasion; the result in most, if not all, cases 
is a local tuberculosis in the adjacent lymphatic glands, and, later, a 
general miliary tuberculosis. 

The same author made, more recently, a long series of experiments 
on dogs, to ascertain the different avenues through which tubercular in- 
fection is known to take place. Tubercular sputum and pure cultures in- 
serted into the lower conjunctival sac in healthy dogs produced tissue- 
hyperplasia at the seat of inoculation, and was followed by infection of 
the cervical glands on the corresponding side. Some of the glands under- 
went caseation, and the presence of bacilli could be demonstrated in all 
of the pathological products. In other animals the tubercular material 
was introduced into the nasal cavity. The cervical glands, especially 
those on the corresponding side, became enlarged and caseated. Infection 
through the mouth, by depositing the tubercular material in a depression 
made with a blunt instrument between the canine teeth, resulted also 
in tuberculosis of the glands of the neck. Infection of the external meatus 
of the ear, without creating an infection-atrium intentionally, was fol- 
lowed by infection of the lymphatic glands behind the ear and along the 
neck on the same side. Cutaneous tuberculosis in the form of an ulcer- 
ating lupus was produced by shaving the skin on one side of the nose 
and face, and scratching it with a finger-nail infected with a pure culture. 
Injection of pure cultures into the healthy vagina of bitches resulted in 
local tuberculosis and secondary infection of the inguinal glands. Inocu- 
lations of other parts were followed by the same train of symptoms: local 
tuberculosis at the seat of infection, followed by dissemination of the 
process along the course of lymphatic channels. The lungs were found 
affected only in two of the animals. These experiments show conclusively 
that the bacillus of tuberculosis, introduced through superficial peripheral 
infection-atria, seeks the lymphatic channels, through which it is ex- 
tensively disseminated before general infection takes place. Cornil and 
Leloir implanted lupous' tissue into the peritoneal cavity of guinea-pigs, 
and in 5 cases out of 14 experiments produced peritoneal and general 
tuberculosis. Pagenstecher and Pfeiffer took the secretion of the con- 



484 PRINCIPLES OF SURGERY. 

junctiva from patients suffering from lupus of this structure, and injected 
it into the anterior chamber of the eye in rabbits. After five to six weeks 
nodules could be seen on the surface of the iris, which, on examination, 
were found to be in every respect identical with tuberculosis of this organ. 
Doutrelepont inoculated the peritoneal cavity in 50 guinea-pigs, and in 8 
rabbits the anterior chamber of the eye with the same material, with the 
result that in all of the animals local tuberculosis was produced at the 
point of inoculation, and in 3 of the guinea-pigs and in 1 rabbit the local 
disease was followed by general tuberculosis. 

Inoculations with material from so-called scrofulous glands produce 
the same effect as when lupous tissue is used, and we are, therefore, forced 
to conclude that these glands owe their existence to the same cause. 
Arloing prepared an emulsion from a scrofulous (tubercular) gland, 
caseous in its centre, which was taken from a boy aged 14. This was 
injected beneath the skin of 10 rabbits and the same number of guinea- 
pigs. Visceral tuberculosis developed in all of the guinea-pigs, but the 
rabbits remained healthy, except that 2 showed yellow, caseous granula- 
tions at the seat of inoculation. From these experiments he inferred that 
scrofula and tuberculosis were nearly allied affections, but caused by different 
agents or they were derived from the same virus, of which the activity was 
modified in the scrofulous form. 

That the number of bacilli injected has a great deal to do with the 
result has been satisfactorily demonstrated by Bollinger. He found that 
infectious milk from a tubercular cow, which produced local tuberculosis 
hy intraperitoneal injections, lost its virulence if diluted from 1 : 40 to 
1 : 100. The sputum of phthisical patients was found much more virulent, 
and had not lost its power to produce tuberculosis on being diluted 
1 : 100,000, on being injected into the abdominal cavity or the subcu- 
taneous connective tissue. Feeding experiments with sputum diluted 1 : 8 
yielded negative results. Pure cultures remained virulent when diluted 
1 : 400,000. All the experiments proved that the more concentrated the 
material and the greater the number of bacilli, the more rapid and in- 
tense was the development of the lesion caused by the injection. It was 
estimated that about 820 bacilli were necessary to produce tuberculosis in 
guinea-pigs. Intraperitoneal injections did not always produce peri- 
toneal tuberculosis, and in cases where this did not occur the organs 
affected were the lymphatic glands, spleen, lungs, liver, kidneys, and 
genital organs, in the order of frequency named, showing conclusively that 
localization does not invariably take place at the point of primary in- 
fection. 

Direct intravenous infection by injections of pure cultures, suspended 
in distilled water, is the most effective way in which diffuse miliary tuber- 



tNOCULATION-TUBEROULOSIB IN M\v 485 

culosis can bo artificially produced in animals with unfailing certainty. 
Koch succeeded also in producing the disease in rabbits, guinea-pigs, rats, 
and white mice, by inhalation. A pure culture, suspended in distilled 
water, was used with a hand-spray, and the cages in which the animal- 
were kept were Idled with the infected spray. The animals were killed 
after twenty-eight days, and all of them showed unmistakable signs of 
pulmonary tuberculosis. 

TOXINS OF THE TUBERCLE BACILLUS. 

The tubercle bacillus, like all other pathogenic microbes, when active 
in the living body produces toxins on which its pathogenic action on the 
tissues depends. Maffuci reports the results of many experiments relating 
to the toxic products of the tubercle bacillus. He concludes that cultures 
of tubercle bacilli in which the bacilli have been destroyed contain a toxin 
which is resistant to time, heat, desiccation, sunlight, and the gastric juice. 
This toxin is derived from the bacilli and is set free by their disintegra- 
tion. It is not the product of secretion of the bacilli, nor does it originate 
in the nutrient medium. This poisonous substance is very potent, a 
minute dose being sufficient to cause marasmus. It may be conveyed from 
mother to foetus without the transmission of the bacillus, and can cause 
abortion or premature birth. If the foetus is born alive, marasmus is apt 
to develop. The milk may also contain the toxin. When concentrated, 
it is capable of causing tubercular abscesses. Weak solutions produce 
circulatory disturbances, and catarrhal inflammations are apt to occur: 
processes which have a distinctive effect on the red corpuscles. In chronic 
tubercular processes the elimination of the toxin may cause parenchyma- 
tous nephritis or fatty degeneration of the epithelium of the glomeruli. 
Some of the most efficient antitubercular agents prove curative by neu- 
tralizing the toxin without destroying the bacillus. Among these iodo- 
form and guaiacol are noted examples. 

IXOCULATIOX-TUBERCULOSIS IX MAX. 

The opinion that tubercle is capable of inoculation was held by 
ancient writers, ■ and Laennec himself, after a nick from a saw while 
making a necropsy on a phthisical subject, thought that he witnessed an 
example of inoculation in a small tubercle that developed in the injured 
skin, but twenty years afterward this distinguished clinician was in good 
health, though finally he died of phthisis. 

Schmidt made a number of experiments to ascertain the effect of 
inoculations of superficial abrasions of the skin with the virus of tuber- 
culosis. In guinea-pigs he made abrasions in the skin, to which he applied 
tubercular material and covered the point of inoculation with collodium. 



486 PRINCIPLES OF SURGERY. 

All of his experiments failed in producing tuberculosis, while in the con- 
trol animals, in which the infectious material was introduced into the 
subcutaneous tissue, or into the peritoneal cavity, tuberculosis developed 
without a single exception. He believes that the results of these experi- 
ments are only corroborative of the assertion previously made by Bol- 
linger and Koch, that the susceptibility of the cutis for tubercular infec- 
tion is slight. A sufficient number of authenticated cases, however, have 
been reported, during the last few years, to prove that in man tuberculosis 
is not infrequently contracted by the absorption of tubercular material 
through small wounds and superficial abrasions of the skin. Volkmann, 
a number of years ago, made the statement that tubercular infection 
never takes place through a large operation wound, or at the site of severe 
injuries, but that localization of the bacillus is likely to take place in parts 
the seat of very slight contusions, or what may appear at the time as an 
insignificant injury. He explained this by assuming that the active tissue- 
changes which take place during the process of regeneration after a severe 
trauma prevent the infection. 

In studying the cases of inoculation-tuberculosis, which will be re- 
ferred to below, it will be seen that the infection-atrium was always caused 
by a trivial injury. A very interesting case of inoculation-tuberculosis 
came under my own observation a few years ago. The patient was a 
strong, healthy young woman, with a good family history, who was em- 
ployed in a rag establishment in sorting rags. Two months before she 
came under my care she noticed a small sore on the dorsal side of the 
right index finger, near the metacarpophalangeal joint. The place ulcer- 
ated, and the granulation-tissue which appeared melted rapidly away, 
forming a deep excavation, which had the extensor tendon for its floor. 
Two weeks later a nodule appeared in the course of the lymphatic vessels, 
near the elbow-joint, over the anterior aspect of the arm, which was soon 
followed by the formation of three other nodules between this point and 
the primary seat of infection. General health not impaired in the least. 
Inflamed foci neither painful nor tender on pressure; presented distinct 
evidences of fluctuation. All the foci were excised, and presented the 
characteristic appearances of tubercular tissue. The primary focus, after 
excision, left such a large defect that it was found impossible to close the 
wound by suturing, and consequently the surface was covered with 
Thiersch grafts taken from the arm. Primary union of all the sutured 
wounds and speedy, definitive healing of the defect at the primary seat of 
infection. 

There can be no doubt whatever that in this case infection occurred 
through a small wound of the index finger, by handling contaminated 
rags, which was followed by dissemination of the bacilli through the 



[NOCULATION-TUBEBCULOSIS IN M \ N . 



487 



lymphatic vessels in direct communication with the primary infection- 
atrium. I have had also under treatment a well-marked case of extensive 
subcutaneous tuberculosis of the hand, in the person of the mother of 
so\ rial children who died of pulmonary tuberculosis. The disease orig- 
inated near the tip of the index linger, at the site of a former abrasion, 
in which a papillomatous swelling formed. This ulcerated and healed 
partly, when the disease commenced to spread along the subcutaneous 
connective tissue, and when the patient came under my observation it had 
extended almost over the entire dorsum of the hand. A number of fistu- 
lous openings existed, which discharged daily only a few drops of thin, 
serous pus. The subcutaneous tissue was transformed into a mass of 
granulation-tissue, which was removed with a small spoon through 
multiple incisions, and the wound surfaces were freely iodoformized. The 




Fig. 170. — Inoculation-tuberculosis. Primary infection at the base of the thumb-nail, 
secondary infection through lymphatics of forearm. 



process of repair was slow, but satisfactory. Martin du Magny has col- 
lected the clinical material of cases of inoculation-tuberculosis, and in his 
comments upon the cases asserts that the sputum of phthisical patients 
and animal excretions were the usual carriers of the bacilli; consequently 
the affection is most frequently met with among physicians, nurses, 
butchers, and teamsters. The external appearances, manifested at the 
point of inoculation, consist in the formation of a red nodule in the skin, 
which increases slowly in size and forms miliary abscesses, in which papil- 
lomatous proliferation takes place, and around which a new zone of in- 
filtration forms, which, in turn, again suppurates and becomes papilloma- 
tous. The centre heals with the formation of a flat cicatrix, while the 
destructive process progresses slowly in a peripheral direction. 

Hanot has collected 6 cases, 1 of which came under his own observa- 



PEINCIPLES OF SURGERY. 

tion. In this case the patient was in the third stage of phthisis, and died 
soon after from a tubercular ulcer on the arm of at least two years' stand- 
ing, while the history of cough only dated from the last two months, which 
would show that the cutaneous lesion preceded the pulmonary affection, and 
was the cause of the phthisis. In the cases which he collected the sources 
of inoculation were necropsies on tubercular patients, handling old bones, 
pricking the hand with a fragment of porcelain from the broken spittoon 
used by a phthisical patient, and in 4 of the cases the tubercular character 
of the cutaneous lesion was verified by finding the bacilli. 

Eiselsberg has observed 4 cases of inoculation-tuberculosis during 
the last few years. The first case was a girl 16 years old, in whom the 
disease developed in the track of a perforation of the lobe of the ear 
made preparatory to the wearing of an ear-ring, and which was kept from 
closing by the insertion of a thread. The tubercular product appeared 
in the shape of a hard swelling the size of a hazel-nut. The second case 
was a young man who injured himself with the point of a knife above the 
external epicondyle of the humerus. Eighteen days later a swelling, the 
size of a pea, appeared at the site of injury, with an ulcerated surface 
covered by pale, flabby granulations. In the axilla of the same side one 
of the lymphatic glands was found enlarged to the size of a hazel-nut. 
The third case concerned a woman 50 years of age, who was supposed 
to have infected herself by washing the clothes of a person the subject of 
a tubercular abscess of the spine, and who with her fingers scratched an 
acne pustule on her face. At this point, six to eight days later, a pain- 
ful swelling, the size of a pea, formed, which subsequently became in- 
durated, and opened spontaneously in six weeks. At the end of three 
months the place of inoculation presented an ulcer with indurated margins. 
In the fourth case the inoculation followed in the track made by the needle 
of an hypodermic syringe, in a girl 20 years of age. The swelling which 
appeared opened after six weeks, and a small quantity of pus was dis- 
charged. Four months subsequently the fistulous opening communicated 
with an abscess-cavity, the size of a silver dollar, lined by a wall of granu- 
lation-tissue. In all of these cases no evidence of tuberculosis could be 
detected in any of the internal organs, and the local disease could be 
traced in every instance to some antecedent lesion, through which the 
infection had evidently taken place. The diagnosis in all cases was based 
on an examination of the granulation-tissue for the bacillus of tubercu- 
losis, which was always found present. 

Another case of tubercular infection through ear-rings is related 
from Vienna in a girl, 14 years of age, of a perfectly healthy family, who 
wore ear-rings left to her by a friend who had died of pulmonary tuber- 
culosis. Soon ulcers appeared on the lobes of both ears, the cervical glands 



[NOOULATION-TUBEROULOSIS IN MAN. 489 

became swollen, and percussion and auscultation revealed infiltration of 
the apex of the left lung. Tubercle bacilli were found in the ulcers and 
sputa. This case is only another instance of inoculation-tuberculosis, 
where, from the point of infection, the disease extended along the lym- 
phatic system, and, finally, systemic infection from the entrance of bacilli 
into the general circulation. 

In the cases of inoculation-tuberculosis cited above, infection oc- 
curred through some slight lesion, puncture, or abrasion, which furnished 
the necessary infection-atrium for the entrance of the bacillus into the 
tissues, but a number of cases have been reported by reliable observers 
where infection took place through a larger wound or granulation surface. 
Middeldorpf reports the case of a healthy carpenter, who opened his knee- 
joint by the cut of an ax, and dressed the wound with a soiled hand- 
kerchief. The wound healed kindly, but later the joint became swollen, 
tender, and painful. Eesection w r as performed, and on examining the 
capsule it was found very much thickened. In the granulation-tissue 
tubercle bacilli were found. Wahl amputated the arm of a boy suffering 
from gangrene, the result of an injury, and discharged the patient with 
the wound completely healed, except a small granulation surface from 
which the drainage-tube had been removed. At first the wound was 
dressed by a girl suffering from tuberculosis. The wound soon showed 
all the characteristic appearances of fungous disease, and the lymphatic 
glands became infected from this source. I have seen in numerous in- 
stances large wounds made for the removal of tubercular glands become 
infected a week or tw T o after the operation, after the superficial wound 
had apparently healed. In such cases the overlying cicatrix is subse- 
quently completely destroyed by the granulations underneath. The ener- 
getic use of the sharp spoon and free iodoformization are the only re- 
sources in finally effecting the healing of such wounds. Konig has seen 
16 cases of inoculation-tuberculosis, following operations for tubercular 
disease of bones and joints, and 2 such cases have been described by 
Kraske. Czerny reports 2 cases in which tuberculosis followed in wounds 
treated by Reverdnr's method of skin-grafting. In both instances the pa- 
tients were healthy, and the skin-transplantation was made during the 
treatment of extensive burns. The skin was taken from limbs amputated 
for tubercular affections. In both cases tuberculosis of the adjacent joint 
occurred, and in 1 of them tuberculosis of the granulating surface. A 
number of cases of inoculation-tuberculosis following circumcision are on 
record, in which the infection often occurred in the practice of orthodox 
Jews, who performed the operation in accordance with the directions laid 
down in the Mosaic law^s. The loose connective tissue of the prepuce, richly 
supplied with lymphatics, is an admirable surface for absorption, and, 



490 PRINCIPLES OF SURGERY. 

when infectious material is brought in contact with it. furnishes the most 
favorable conditions for the production of local lesions and the transporta- 
tion of microbes along the lymphatic channels to more distant parts. 

Lehmann has observed 10 cases of inoculation-tuberculosis in Jewish 
boys 3 caused by sucking the wound after ritual circumcision by a phthisical 
person. Ten days after the circumcision the wound became the seat of 
ulceration, and the inguinal glands began to enlarge. Four of the children 
died of tubercular meningitis, and 3 died after a prolonged illness caused 
by multiple tubercular abscesses. Hofmokl has reported a similar ease, 
and Weichselbaum detected the bacillus of tuberculosis in the circum- 
cision wound. 

Elsenberg has described 3 cases of tubercular infection after circum- 
cision. All the cases were infants, and the disease appeared primarily in 
the wound or cicatrix, and, later, in the inguinal glands. Local treatment 
by scraping proved successful. The diagnosis was corroborated by micro- 
scopical examinations of the granulation-tissue. Willy Meyer relates a 
case in which circumcision was performed according to the rules of the 
Jewish Church eight days after birth by an old man, and in which four 
weeks after the ceremony an induration appeared at the frenulum, and 
the inguinal glands about the same time began to enlarge. Syphilis was 
suspected, and the little patient was put on a specific course of treatment. 
The inguinal glands suppurated, and another small abscess formed in the 
right gluteal region. The diseased tissue about the gians penis was then 
excised. Microscopical examination of the granulations revealed the pres- 
ence of miliary tubercles and bacilli in great abundance. The above cases 
furnish abundant and convincing proof of the possibility of the trans- 
mission of tuberculosis by cutaneous inoculation through superficial abra- 
sions, small wounds, and granulating surfaces, and this subject is deserving 
of the most careful attention of surgeons in the matter of prophylaxis, 
diagnosis, and treatment. 

HISTOLOGY OE TUBERCLE. 

A tubercle-nodule is an aggregation of cells primarily invisible to 
the naked eye, the product of a minute focus of inflammation, caused 
by the presence of the essential cause of tuberculosis. When the nodule be- 
comes so large that it can be recognized without the aid of the microscope, 
it already consists of a confluence of a number of minute microscopical 
nodules. Laennec described four varieties of tubercle: 1. Miliary tubercle, 
where the visible product of tubercular inflammation appears as nodules 
the size of a millet-seed, of a grayish color, and usually arranged in groups. 
2. Crude tubercle, where the miliary nodules have become confluent and 
have undergone caseous defeneration. 3. Granular tubercle, where the 



BISTOLOGT OF TUBEBCLE'. 491 

nodules are extremely small, nearly the Bize of a millet-seed, and scattered 
uniformly through a whole organ. They are not arranged in groups and 
have no tendency to become confluent. In the centre they become trans- 
formed into yellow tubercle. 4. Encysted tubercles, or such as are consti- 
tuted of a hard mass of mule tubercle in the centre surrounded by a firm 
fibrous capsule. These varieties only represent different phases of the 
same process and different stages of inflammation produced by the same 
cause. The anatomico-pathological basis of tubercle was created by Yir- 
chow, and has been firmly established through the laborious researches 
of Langhans, Wagner. Klebs, Schueppel, Rindfleisch, Koester, Friedlander, 
Fox, Baumgarten, and many others. The specific-cell theory has had 
many able advocates, and has been the subject of many animated discus- 
sions, but it has at last been abandoned as fallacious and unscientific. 
There are no specific tubercle-cells. 

Lebert's tubercle-corpuscle is a thing of the past, and is only referred 
to as a landmark in the history of tuberculosis. Eeinhart showed that 
these cells, which were regarded by Lebert as characteristic and pathogno- 
monic of tubercle, could be found in all products of chronic inflammation, 
and their presence was only an evidence that a certain amount of inflam- 
mation existed. When we speak of a tubercle, we mean a nodule or 
granule, which is composed of leucocytes derived from the capillary yessels 
damaged by the bacillus of tuberculosis, or new cells derived from tissue- 
proliferation of preexisting cells acted upon by the same cause. The 
anatomical character of the nodule consists, not in the presence of any 
particular cell-element, but in the peculiar arrangement of the cells; and 
this feature is the only reliable anatomical guide in making a diagnosis 
by the use of the microscope. The product of tubercular inflammation 
occurs either in the form of submiliary, microscopical granules, visible 
miliary nodules, or a cheesy infiltration, which may occupy an entire 
organ, as a lymphatic gland, or large, isolated foci, as in bone. Every 
tubercular product commences as submiliary nodules, which, when they 
become confluent, are transformed into visible gray miliary nodules, which 
again coalesce* after they have undergone caseous degeneration: form cheesy 
masses, which may be either small and circumscribed or large and diffuse. 

Yirchow defines tubercle as a nodule representing a heterogeneous 
growth: a product originally necessarily of a cellular nature, taking its 
starting-point from the connective tissue or from other mesoblastic struct- 
ure, as marrow, fat, or bone. He asserts that the microscopical or sub- 
miliary granule contains all of the essential histological elements of 
tubercle, and by aggregation forms the ordinary miliary nodule of Laen- 
nec. When the nodules become confluent they may form masses the size 
of a walnut, surrounded by a common zone of embryonal tissue. The 



49.2 PRINCIPLES OF SURGERY. 

yellow tubercle, the crude tubercle of Laennec, is a more advanced stage 
of the gray, the histological elements of the latter having undergone 
caseation. 

HISTOGENESIS OF TUBERCLE. 

Schick endeavored to end the dispute still existing between the 
school of Metschnikoff and that of Baumgarten relative to the part taken 
by the fixed tissue-cells in the formation of tubercle. The former, as is 
well known, referred all cellular elements of the tubercular inflammatory 
product to the leucocytes, while the latter holds that they originate chiefly 
from the fixed cells, leucocytic infiltration occurring later as a secondary 
feature. He confirms Baumgarten's views of the participation of the 
fixed cells by his own investigations and asserts that the number of leuco- 
cytes depends on the character of the region of inoculation, and the quan- 
tity and quality of the bacilli. As in Baumgarten' s experiments the eyes 
of the inoculated rabbits were constantly kept under the influence of 
atropia, which retards leucocytic immigration, that observer necessarily 
obtained different results regarding the participation of the white cor- 
puscles. In studying the histology of tubercle-tissue the unprejudiced 
student will find that the preexisting tissue takes the first and most im- 
portant part in the formation of the inflammatory product, but the leuco- 
cytes constitute an important element in the histogenesis of the nodules, 
particularly in its periphery. 

Colberg asserts that tubercles in the lungs originate from the nuclei 
of the capillary vessels and the connective tissue, the epithelial cells 
lining the alveoli never being primarily affected. Bastian observed 
tubercle-nodules upon the small vessels in cases of basilar meningitis, 
but refers their origin, not to proliferation of the nuclei of the endothelial 
lining of the vessels, but to new cells springing from the endothelial cells 
of the perivascular lymphatic sheaths which surround the vessels of the 
meninges of the brain. 

KnaufT demonstrated the lymphoid character of the adventitia by 
examining the capillary vessels of the visceral pleura in dogs which had 
been exposed for a long time to an atmosphere impregnated with coal- 
dust. He found the pigment lodged in small masses close to the walls 
of small arteries and veins. Examining the same vessels in other dogs 
not thus treated, he found upon the outer surface of the adventitia opaque, 
whitish-gray nodules, surrounded by round and oval cells containing 
nuclei, also lymph-corpuscles. The same structures, which he named 
lymph-nodules, are also found around the same vessels of the pleura in 
man, and Knauff looks upon these lymphoid structures as the starting- 
point of tubercular inflammation. 



HISTOGENESIS OF TUBERCLE. ISKj 

Klebs maintains that the endothelial eells of lymphatic: vessels are 
the most frequent location for the formation of the primary tubercle- 
nodule. He observed that in cases of tubercular ulceration of the intes- 
tines the peritoneum is reached through the lymphatic vessels. Silver- 
stained preparations of inoculation-tuberculosis in rabbits showed that 
the most recent products occurred in the interior of the lymphatic vessels 
at points of intersection. In some places the nodules extended into the 
tissues between the lymphatic vessels, but their centre always corre- 
sponded to the location of a lymphatic vessel. At some points the nodules 
were seen to branch out, but these projections, in reality, were within the 
lymphatic vessels, as the net-work of lymphatic endothelia could be seen 
above and underneath the tubercular product. Toward the centre of the 
nodule no endothelial cells could be distinguished, and this fact led him 
to the belief that the endothelial cells are directly concerned in the pro- 
duction of the new tissue. In the mesentery he saw the tubercles adhere 
to the outer wall of the capillary vessels, and, as the spindle-shaped cells 
of the outer coat appeared to be pushed apart by the new tissue, he 
regards the adventitia as a genuine lymphoid structure. Kindfleisch traces 
the beginning of the process in miliary tuberculosis of the lungs to a 
proliferation of the endothelia and the external connective-tissue layer of 
the capillary lymphatic vessels. Edward Smith believes in the epithelial 
origin of tubercle. Manz studied the development of tubercle in the 
choroid in patients suffering from general miliary tuberculosis. So con- 
stantly does this disease show itself in this structure that von Graefe, 
Cohnheim, Frankel, and Bouchut recommend ophthalmoscopic examina- 
tion as a diagnostic measure in cases of suspected pulmonary or general 
tuberculosis. Manz traces the commencement of the disease in the cho- 
roid to cell-pullulation in the tunica adventitia of the small vessels. The 
process is, however, not limited to this structure; the non-pigmented 
stroma-cells may also assist in furnishing material for the new product. 
Barth, on the other hand, asserts that the vessels, in cases of tuberculosis 
of the choroid, are not primarily affected; according to his observations, 
the process depends exclusively on a degeneration of the stroma-cells, as the 
remaining tissue did not appear affected. 

Cohnheim, Ziegler, and others maintain that the leucocytes furnish 
most of the material in the building up of the tubercle-nodule. 

Experiments on animals, as well as microscopic examinations of 
pathological specimens, have sufficiently demonstrated the fact that the 
tubercle-nodule is nothing more nor less than a circumscribed inflamma- 
tory product, the histological elements of which are composed of new 
tissue, formed by proliferation of fixed tissue-cells which have come in 
contact with the bacillus of tuberculosis or its toxins. The specific pa- 



494 PRINCIPLES OF SURGERY. 

thogenic effect of the bacillus consists in its power to cause a chronic 
inflammation of the tissues in which it has localized or with which it has 
been brought in contact. The tissues affected are the cells which are 
nearest the essential microbic cause, irrespective of their embryological 
origin, their histological structure, or physiological function. In cases 
of inoculation-tuberculosis the primary nodule develops at the point of 
insertion of the virus from connective-tissue proliferation, and from here 
the bacilli enter the lymphatic channels, and the secondary nodules are 
composed of cells derived from the endothelial, lymphoid, and connective- 
tissue cells which compose these structures. If the bacilli are injected 
in sufficient quantity directly into the circulation or gain entrance into 
the blood-current from some tubercular focus, they become implanted 
upon the wall of distant capillary vessels, and the nodule which forms at 
the seat of implantation consists of cellular elements formed by the tis- 
sues of the vessel-wall. As soon, however, as bacilli reach the extra- 
vascular tissues, they, in turn, furnish their part of the material for the 
further growth of the nodule. If the tubercle bacillus becomes implanted 
upon a mucous surface, as the bladder, intestines, nose, larynx, uterus, 
etc., if such surface is susceptible to tubercular infection, the epithelial 
cells take an early and active part in the inflammatory process. From 
the manner of entrance into and diffusion through the tissues, it is ap- 
parent that the mesoblastic tissues, the connective-tissue and endothelial 
cells, being the first to become infected, furnish the greatest amount of 
material in most tubercular lesions; but all tissues, when infected, take 
part in the process. 

HISTOLOGICAL STRUCTURE OF TUBERCLE. 

The essential histological elements which make up a primary tubercle 
nodule are: (a) leucocytes; (b) giant cells; (c) epithelioid cells; (d) reticu- 
lum. 

Leucocytes. — One of the convincing proofs of the inflammatory nature 
of tuberculosis is the presence of leucocytes in the tubercle-nodule. The 
bacillus of tuberculosis appears to exercise only a mild pathogenic effect 
on the capillary wall, and the primary inflammatory product is always 
scanty. As the colorless blood-corpuscle can only escape, in considerable 
number, through inflamed capillary walls which have undergone alteration 
from the action of some specific microbic cause, it is evident that its 
migration into the paravascular tissues, where it forms a part of the 
tubercular product, can only occur after such alteration has taken place 
from the action of the bacillus upon the cement-substance of the endo- 
thelial lining of the capillary vessels. The leucocytes are found scattered 
among the cellular elements, and are found in greatest abundance toward 



HISTOLOGICAL STRUCTURE OF TUBERCLE. 495 

the periphery of the nodule. (Fig. 172.) The leucocytes invariably 
undergo degenerative changes, and are never transformed into other 
forms of cells found in the tubercular product. They have been described 
as lymphoid corpuscles. Although constantly present, they are most 
numerous when the process is acute. 

Giant Cells. — A great deal has been said and written concerning the 
origin and diagnostic value of the giant cells in the tubercle-nodule. 
They resemble the giant cells found in some forms of sarcoma, and appear 
to be simply certain cells which have outgrown others by taking up a greater 
amount of nourishment in the shape of leucocytes which have undergone 
fragmentation. 

The giant cells, or, as Klebs calls them, macrocytes, are finely granular, 







■: *» 






B 



'•:>£ <y 



Fig. 171. — A Lupous Nodule Situated Deeply in the Corium. The specimen is inter- 
esting because of the great number, size, and characteristics of the giant cells. A, con- 
nective tissue of corium; B, giant cell; C, small, round-cell infiltration. (Stained by- 
polychrome methylene-blue.) 

and contain multiple nuclei, which usually occupy the periphery of the cell, 
or are arranged in a crescent at one end. In tubercular lesions artificially 
produced in animals the giant cells contain numerous bacilli, which occupy, 
as a rule, the peripheral zone of the cells. In tuberculosis in man the bacilli 
in these cells are never so numerous, and as central degeneration of the cells 
appears they disappear in this portion of the cell, while some may still be 
found in the periphery. During the progress of the disease the giant cell 
becomes more and more fibrous toward the periphery, at the expense of the 
protoplasmic part in the centre. The protoplasm evidently is transformed 
into or secretes the fibrous margin. If caseation does not take place the 



496 PRINCIPLES OF SURGERY. 

bacilli disappear, and the whole cell-mass, including the giant cells, is con- 
verted into a cicatricial mass. 

The first evidences of degeneration appear in the centre of the giant 
cells, and, according to TVeigert, they consist of structural and chemical 
changes which are indicative of coagulation-necrosis. 

In a recent tubercle-nodule the giant cells occupy the central portion, 
around which the epithelioid cells and leucocytes are arranged. The vacu- 
oles are necrotic foci within the cells. 

The giant cell found in tubercular tissue has its prototype in normal 
tissue. Giant cells were first discovered in normal tissue (marrow of bone) 
by Robin, who called them my elo plaques. They were subsequently accurately 
described bv Yirchow. In a normal condition thev are constantlv found in 




Fig. 172. — Tubercle-nodule in Lymphatic Gland. A. multinuclear giant cell: D. 
epithelioid cells; C, leucocytes and lymphoid corpuscles. X 500. 

bone and the placenta. They are also found occasionally in fat-tissue, espe- 
cially in cases of rapid emaciation. Kundrat has found them in inflamed 
serous membranes, and Strieker and Heitzmann in the inflamed cornea. 
They are always found around foreign bodies, becoming encysted in the 
tissues. Friedlander found them present in the alveoli of the lungs in cases 
of chronic pneumonia. 

Heubner found giant cells in endarteritis, Baumgarten in gummata, 
Buhl and Jacobson in granulating wounds, and finally Johne and Pflug in 
actinomycotic foci. The histological source of these cells in tubercular af- 
fections has been traced to epithelial cells by Zielonko and Weigert; to endo- 
thelial cells by Kundrat, Klebs, Herrenkohl, and Zielonko; to connective 
tissue or endothelial cells by Yirchow, Fleming, and Ziegler. Schueppel 



BISTOLOGIOAL STRUCTURE 01 TUBERCLE. 



p.»; 



and Rindfleisch believe thai they invariably originate within blood-vessels 
or lymphatics, where these authors regard them as the first step toward the 
development of tubercle-nodules. Ziegier claims to have seen giant cells 
develop from while blood-corpuscles. Hering, Aufrecht, Woodward, 
Schueller, and Treves are of the opinion that what appear as giant cells 
in tubercular tissue are not cells, but only represent spaces which correspond 
to transverse sections of lymphatic channels, the protoplasm representing 
the coagulated lymph within these vessels, and what appear as nuclei being 
enlarged, swollen endothelial cells. Giant cells possess amoeboid movements, 
and by virtue of these they are capable of taking up in their protoplasm fine 
particles, such as microbes, pigment-material, and blood-corpuscles which 
have undergone fragmentation. The giant cells in tubercular lesions are 








Fig. 173.— Giant Cell from Centre of Tubercle of Lung. A, granular protoplasmic 
centre; B, peripheral more-formed part; C, crescent of nuclei; D, endothelium-like 
cells; E, two vacuoles within the giant cell. X 450. (Hamilton.) 

hyperplastic, epithelioid cells, and consequently are derived from the same 
histological sources as these. 

Epithelioid Cells. — Cells intermediate in size between the giant cells 
and the leucocytes are found in every tubercle-nodule in which the cells have 
not been destroyed by caseation. These cells were first described by Rind- 
fleisch, and were called by him epithelioid cells from their structural resem- 
blance to epithelial cells. Klebs calls them platycytes. 

They are about two or three times larger than a white blood-corpuscle, 
and in shape they are either round or somewhat elongated. In structure 
they are finely granular, and contain one large and often a number of small 
nuclei. They form the bulk of all recent nodules, are scattered between the 
giant cells, and are often arranged in layers around them. The histological 



498 



PRINCIPLES OF SURGERY. 



source of these cells was supposed to be the leucocyte by Schueppel, Ziegler, 
and Treves; the endothelial cells of the lymph-spaces by Aufrecht, Hering, 
and Woodward; the endothelial cells of the blood-vessels and lymphatics 
or connective-tissue cells by Kindfleisch and nearly all of the modern au- 
thors. The epithelioid cells are the embryonal cells, the product of prolifera- 
tion from any of the fixed tissue-cells in a tubercular lesion, and they remain 
as such until they are destroyed by degenerative changes from the continued 
action upon them of the bacillus of tuberculosis or its toxins, or until, on 
cessation of the primary cause, they are transformed into tissue of greater 
durability. 

Reticulum. — Schueppel first called attention to the reticulated struct- 




Fig. 174. — Tuberculosis of Trochanteric Bursa. A, A, A, A, giant cells; B, caseous 
contents of bursa; G, epithelioid cells and leucocytes. X 200. 

ure of tubercle by his description of the reticular arrangement within tuber- 
cles of lymphatic glands. 

The recticulum, according to most authors, consists of the preexisting 
connective tissue pushed asunder by the new cells. According to Wagner, 
Schueppel, Brodowski, Thaon, and Ziegler, it is made up of protoplasm. 
Buhl taught that the giant and epithelioid cells secrete a substance at their 
periphery which, on becoming firm, is formed into a structure resembling- 
connective tissue. According to his researches, only the marginal zone is sup- 
plied with loose, ready-formed, connective tissue of the organ. TTahlberg 
maintained that the principal reticulum consists of protoplasm which is 
traversed by a net-work of connective tissue. The reticulum is always more 
marked in the periphery of the tubercle-nodule, where, from pressure, it is 
condensed into a fibrous capsule (Fig. 176, C). 



histological STRUCTURE OF TUBERCLE. L99 

Arrangement of the Cells in a Recent Tubercle-nodule. — A fully-de- 
veloped typical tubercle is called a Langhans tubercle because it was first ac- 
curately described by this author. The earliest evidence of the formation 
of a tubercle-nodule, as witnessed under the microscope, is the appearance 
o( small cells which resemble ordinary embryonal cells, which are the prod- 
uct of tissue-proliferation from a mesoblastic matrix, usually the connective 
tissue, and its embryological and histological prototype, the endothelial cells 
of blood-vessels and lymphatics. From these cells the epithelioid and giant 
cells are. later, developed. Some of the central cells, by appropriation of a 
superabundance of food furnished by leucocytes in a state of fragmentation, 
become hyperplastic, and are transformed into giant cells; these occupy the 
centre of the nodule. Around these cells the smaller or epithelioid cells 




Fig. 175. — Section from Mucous Membrane of Pharynx, showing Epithelioid Cells with 
a few Small Giant Cells. X 350. (Birch-Hirschfeld.) 

arrange themselves, and between them and in the priphery of the nodule 
are found the smallest cells: the leucocytes. 

Gaule and Tizzoni distinguish three zones in a tubercle: (1) an external, 
composed of small, round cells; (2) a lesser, epithelial, or middle zone, con- 
taining the reticulum; (3) a central space containing a giant cell. The 
structure of a tubercle is not always typical, and hence the division into 
zones is based more on theoretical grounds than actual observation. The 
giant cell is not an essential histological element of tubercle, but an acci- 
dental product. In some tubercles giant cells cannot be found, while in 
ethers they are numerous. Giant cells can only develop from epithelioid 
cells if the local conditions are favorable for hypernutrition; that is, if the 
leucocytes in a condition of fragmentation are within their reach. If they 



500 



PRINCIPLES OP SURGERY. 



are present they always mark the location of the starting-point of the tuber- 
cular infection, as only the older epithelioid cells undergo this change. The 
number and size of the epithelioid cells are also subject to great variation, 
and are modified by the nutritive conditions within and in the immediate 
vicinity of the nodule. If cell-proliferation is active the epithelioid cells 
appear densely packed in the reticulum, nutrition is greatly impaired, and 
the new cells undergo degenerative changes before they attain their average 
size. The leucoc}^tes are scattered among the giant and epithelioid cells, 




Fig. 176.— Fully-Developed Reticular Tubercle of Lung. A, A, A, giant cells; B, 
vacuole in one of these; C, peripheral capsule of fibrous tissue; D, reticulum of the 
tubercle; E, large endothelium-like cells lying on the reticulum and within its meshes; 
F, smaller "lymphoid" cells occupying the same situation; G, peripheral fibrous-look- 
ing border of the giant cells. X 450. (Hamilton.) 

and, as they reach the part through the inflamed wall of the capillaries in the 
immediate vicinity, they are most numerous in the periphery of the nodule 
and along the course of the affected vessels. 



GROWTH OF THE TUBERCLE-NODULES. 



The typical tubercle-nodule is microscopical in size. The growth of 
the swelling depends on the formation of new tissue, migration of leucocytes, 
and confluence of nodules into larger masses. The bacillus of tuberculosis, 



PATHOLOGICAL VARIETIES OF TUBERCLE. 501 

when brought in contact with fixed tissue-cells susceptible to its pathogenic 
action, incites tissue-proliferation, which always takes place by karyokinesis. 
Baumgarten's investigations leave no doubt that phatycytes constitute the 
entire mass of the forming tubercle. He has also observed karyokinetic fig- 
ures in tubercular tissue in cells derived from the connective tissue, endo- 
thelia, and epithelia. The tubercle bacilli are found in the interior of giant 
and epithelioid cells and between them. 

Each tubercle-nodule increases in size by the growth of new cells from 
preexisting tissue; and. as the primary cause, the bacillus of tuberculosis, 
multiplies in the tissues, bacilli are conveyed into the surrounding tissues by 
leucocytes or the plasma-current, and new centres for tubercle-formation 
are established, which, later, become confluent, forming masses of consider- 
able size, the numerous foci of caseation corresponding to the centres of so 
many nodules. The growth of tubercle is favored by local and general con- 
ditions which diminish tissue-resistance, while retardation takes place in 
consequence of degenerative changes in the cells of which it is composed, 
or, if the cells are converted into tissue of a higher type, from disappearance 
or suspension of activity of the primary cause. 

PATHOLOGICAL VARIETIES OF TUBERCLE. 

Several varieties of tubercle have been described, according to the his- 
tological structure of the tubercle or the structure or condition of the cells 
of which it is composed. 

Reticulated Tubercle. — This is the ordinary form of tubercle usually 
met with, and the most important anatomical feature is the presence of a 
well-defined reticulum, composed of preexisting connective tissue and a 
delicate net-work of branching giant cells, in the meshes of which are found 
the epithelioid cells and leucocytes. 

Fibrous Tubercle. — In contradistinction to the reticulated or lymphoid 
tubercle, a few years ago the fibrous tubercle was described, distinguished 
by its pearl-like, light-gray appearance, but possessing the same inherent 
tendency to caseation. It is said to be found most frequently in dense, 
fibrous tissue, and quite often in newly-formed connective tissue. Histo- 
logically it is composed of nodules of dense connective tissue, the cells of 
which have undergone rapid growth, containing, frequently, more than one 
nucleus. A further development only takes place in the interior of the 
nodule, as here caseation occurs, the caseous focus being surrounded by a 
firm capsule of connective tissue. The description of fibrous tubercle by 
Langhans differs materially from the above. According to investigations of 
this author, the fibrous tubercle has for its favorite location the so-called 
parenchymatous organs, as the lungs, liver, spleen, kidneys, testicles, epi- 
didymis, and brain. The larger nodules are composed of three zones. The 



502 PRINCIPLES OF SURGERY. 

central zoiie consists of a few connective-tissue fibres, free oil-globules, and 
cells in a condition of fatty infiltration. The middle zone is composed of con- 
nective tissue. As the cells of this zone are not numerous, it presents the 
appearance of a capsule; in reality, however, it is not a capsule in the proper 
sense of the word, but a matrix of tissue-proliferation, from which the cen- 
tral part of the tubercle is the offspring. Both Langhans and Schueppel, 
like nearly all of the modern pathologists, regard fibrous tubercle not as a 
distinct special anatomical form, but as an ordinary tubercle in which the 
epithelioid cells in the peripheral zone have been converted into connective 
tissue. Fibrous tubercle differs from the ordinary cellular variety only in 
so far that it contains a larger amount of connective tissue. If in a tubercle- 
nodule at the time the young cells are yet vigorous the primary microbic 
cause ceases to act, degenerative changes fail to take place and the embryonal 
cells are transformed into connective tissue. The cicatricial condition 
starves out remaining embryonal cells. At the same time an impermeable 
wall of connective tissue is thrown around the primary depot of infection, 
which effectually guards against the escape of active bacilli or their spores 
into the surrounding tissues. 

Hyaline Tubercle. — Chiari described another variety of tubercle: the- 
hyaline tubercle. The first specimen in which he found this variety was 
taken from the liver of a tubercular child -i years of age. The nodules in 
the brain, lungs, and bronchial glands in the same case presented the ordi- 
nary structure of lymphoid tubercle. The clear hyaline structure of those 
found in the liver gave them a very peculiar appearance. The change is 
believed to be due to a hyaline degeneration of the reticulum, and resembled 
most closely the hyaline degeneration of the capillaries of the brain. Chiari 
conjectures that it may be regarded as a benign change opposed to casea- 
tion, which tends to infection. Hyaline degeneration of any pathological 
product must now be considered as one of the earliest phases of coagulation- 
necrosis, and, if a considerable area of the nodule undergo this change rap- 
idly and simultaneously, the structures will present a hyaline appearance; 
but, if the hyaline product continue to be acted upon by the same causes, 
caseation will follow, and the hyaline tubercle becomes a cheesy tubercle. 

CASEATIOX. 

The gray, or miliary, tubercle is transformed into the yellow, crude, or 
cheesy tubercle by a process which is called caseation, or tyrosis. The exact 
nature of this process remains unknown. The cheesy material is composed 
of the products of cell-necrosis. Early death of cells is the most character- 
istic pathological feature of tubercle, which distinguishes it from all other 
forms of chronic inflammation. Two causes can be advanced to explain this 
peculiar and almost pathognomonic form of degeneration, which occurs, 



CASEATION, 



503 



almost without exception, in every tubercle if a sufficient length of time has 
elapsed: 1. Inadequate blood-supply. 2. Specific action of the bacillus of 
tuberculosis or its toxins. Caseation always commences in the centre of a 
nodule, consequently at a point most remote from the vascular supply, and 
in cells which have been exposed longest to the deleterious effect of the pri- 
mary microbic cause. Tubercle is a non-vascular product. From causes 
which, as yet, are not known, the tubercular product is not supplied with 
new blood-vessels. The angioblasts are transformed into epithelioid cells 
that have lost their power of vessel-formation. Nodules which have pri- 
marily an intravascular origin are rendered avascular by closure of the vessel 
from intravascular and perivascular cell-proliferation. If the primary start- 




Fig. 177. — Tuberculosis of Trochanteric Bursa. Recent area of invasion, showing blood- 
vessels. A, A, blood-vessels; B, B, giant cells; G, C, epithelioid cells. X 500. 



ing-point is outside of the vessels, the rapidly-accumulating cells exert press- 
ure upon the surrounding vessels, and thus diminish the blood-supply to 
the part affected. The new cells require an adequate blood-supply for 
their further development, and if this fail to take place, as is the case in 
every tubercular product, they necessarily suffer from malnutrition, and un- 
dergo degenerative changes at an early stage of their existence. A deficient 
blood-supply, in the absence of other causes, would result in fatty degenera- 
tion of the new tissues; but caseation is something different from ordinary 
fatty degeneration, and the bacillus of tuberculosis or its toxins must be re- 
garded as its immediate and essential cause. Caseation is preceded by coag- 
ulation-necrosis, which is one of the results of the specific action of the 
bacillus on the tissues. The coagulation-necrosis commences in the giant 



504 



PRINCIPLES OF SUEGERY. 



cells, and in the epithelioid cells in the centre of the nodule, and caseation 
follows as soon as the dead cells have lost their histological identity and 
appear under the microscope as a debris in which no distinct cell-forms can 
be identified. Caseation is attended by softening, which can be readily rec- 
ognized in tubercular masses the size of a hazel-nut to that of a walnut, com- 
posed of numerous confluent nodules with as many caseating foci. 

In such masses the small, cheesy cavities become confluent and form 
spaces of considerable size. Caseation proceeds from the centre of each- 
nodule toward the periphery, layer after layer of epitheloid cells being de- 
stroyed and changed into cheesy material. The part of a tubercle-nodule 
which has undergone caseation contains few or no bacilli, and yet inocula- 



0. 








Fig. 178. — Caseated Submaxillary Gland. A, connective-tissue capsule of gland; 
B, small, round cells of gland, indistinguishable except by number from gland-lympho- 
cytes proper; C, area of caseation; D, giant cells. 



tion experiments show it to be highly infectious. The cheesy material does 
not furnish the proper nutrient material for the growth and development of 
the bacillus, which dies from starvation, while the spores, being more dur- 
able and possessing greater power of resistance, remain in an active condi- 
tion for an indefinite period of time in the dead material, and it is due to 
their presence that infection takes place from cheesy foci and that successful 
inoculations can be made with cheesy material. "While the disease has be- 
come arrested in the centre of a nodule, with the appearance of caseation, 
its growth in a peripheral direction pursues the same relentless course. The 
bacilli multiply in fresh tubercular tissue, and are carried beyond the pe- 
ripheral zone into the surrounding tissues, where new, independent foci of 
infection are thus established, which, in the course of time, pass through 



CALCIFICATION. 505 

the same series of pathological changes as the primary nodules. It is a well- 
known clinical fad thai acute miliary tuberculosis is not a primary affection, 
as in all such cases a careful post-mortem examination will reveal the pres- 
ence of a cheesy focus in a lymphatic gland, the lungs, testicles, a joint, or 
bone, or some other organ from which the infection occurred. Weber found 
cheesy foci in 16 cases of tuberculosis of serous membranes. The cheesy 
mass may lie latent so long as it is solid, but as soon as it liquefies the spores 
which it contains can be taken up by the blood-vessels and become the cause 
of general infection. 

CALCIFICATION. 

One of Nature's means in preventing the local extension of tubercle 
and in guarding against regional and general infection is calcification of the 
tubercular product. This can only occur as a secondary condition in tuber- 
cles that have undergone caseation. Calcification implies the removal of 
the cheesy material and the substitution for it of inorganic, calcareous ma- 
terial. It is a process which greatly resembles petrifaction. Arrest of the 
tubercular process by caseation and calcification frequently takes place in 
the lungs, and, occasionally, in the lymphatic glands. 

32a 



CHAPTER XX. 

Clinical Forms of Surgical Tuberculosis. 

It is but a few years since it was thought impossible that any other 
organ than the lungs could be the seat of tuberculosis. The different forms 
of surgical tuberculosis that will be described below were not correctly un- 
derstood until quite recently, and consequently a rational surgical treatment 
was out of question. Most all of the localized tubercular processes were in- 
cluded under the general term scrofula, and were regarded as local mani- 
festations of a general dyscrasia, and treated in accordance with this view 
of their pathology. The discovery of the bacillus of tuberculosis has ren- 
dered the word scrofula obsolete, and has assigned to the tubercular proc- 
esses in the various organs and tissues of the body their correct etiological 
and pathological significance, and paved the way for their more successful 
surgical treatment. There is hardly a tissue in the body which may not be- 
come the primary seat of tubercular infection, or which escapes when diffuse 
dissemination occurs through the medium of the general circulation. The 
frequency of tubercular affections is something appalling. At least 1 person 
out of every 7 dies of some form of tuberculosis. Most of the large hospitals 
contain from 25 to 50 per cent, of patients afflicted with this disease. The 
ravages of the disease are to be seen everywhere, in the shape of disfiguring 
scars of the neck, deformed limbs, and bent spines. Health resorts, fre- 
quented for years by tubercular patients, have become infected to such an 
extent that there is great danger of the whole population becoming exter- 
minated by this disease. The sources of infection in such places have be- 
come so numerous that it is unsafe to breathe the air, to drink the water, 
or to eat the food prepared in houses which for years have been hot-beds 
for the bacillus of tuberculosis, and by persons carrying the microbe upon 
every square inch of their surface. That whole communities and nations, 
where this disease has been prevalent for centuries, have not been completely 
depopulated long ago is owing to the fact that many persons possess, from 
the time of their birth, a degree of resistance to infection that even direct 
infection by inoculation would prove harmless. The bacillus is not the sole, 
but the essential, cause of tuberculosis. 

HEREDITARY AND ACQUIRED PREDISPOSITION. 

Almost every author recognizes, as an important element in the etiology 
of tuberculosis, the existence of an hereditary or acquired predisposition. 
Little is known in reference to the real nature of such a predisposition. A 
weakness of the lymphatic vessels in scrofulosis was recognized by Sylvius 

(506) 



!m:i;i:i>itai;y and AOQUIBED PBEDISPOSITION. 507 

as early as 1695, by Tonal in 1690, and still later by Bell, Percival Pott, 
Hufeland, and Broussais. Fox is of the opinion that a disposition to tuber- 
culosis is created by certain anatomical or physiological defects in the lym- 
phatic system. The cause of scrofula was ascribed by Virchow to a weakness 
or imperfection in the arrangement of the lymphatic system; by Hueter to a 
dilatation of lymph-spaces; and by Billroth to a constitutional anomaly. 
Mordhorst regards a sluggish circulation, the consequence of superficial, im- 
perfect respiration, by causing capillary stasis and favoring inflammatory 
exudation, a potent factor in producing that peculiar vulnerability of the 
tissues in scrofulous subjects. Eokitansky placed great stress on the impor- 
tance of an imperfect circulatory and respiratory apparatus as a predispos- 
ing cause of tuberculosis. In 1871 Friedlander suggested that in cases of 
tuberculosis there might be present, and active, a fusion of the scrofulous 
and tubercular diathesis: a view which was indorsed by Charcot in 1877. 
Aufrecht claims that the disposition to the origin of tubercle may be found 
in the lymphatic vessels. Eiedel defines the hereditary predisposition to 
tuberculosis as consisting in a peculiar defect in the anatomical arrangement 
of the tissues, especially of the lymphatic glands, which furnish a favorable 
soil for infection. Schttller believes that the noxae of tuberculosis excite a 
slow form of inflammation, with a tendency to speedy retrograde metamor- 
phosis of the new material. Quincke recognized a close relationship between 
scrofula and tuberculosis, when he says: "Scrofulous persons are especially 
predisposed to tuberculosis; tuberculosis hardly ever occurs except in scrof- 
ulous persons." Ziegler was aware that pulmonary phthisis is the most fre- 
quent cause of death in scrofulous patients. 

AYhittaker, in comparing the etiology of tuberculosis with syphilis, 
makes use of the following very positive language: "There is no such a thing 
as a predisposition to either disease. Either a man has syphilis or he has it 
not. One man is not more predisposed to either disease than another. Syph- 
ilis affects one individual more than another because its virus finds a better 
lodgment upon mucous membrane. Tuberculosis finds, also, fortuitously, 
a better nidus in one case than another. The virus of tuberculosis is lodged, 
in one case, and not coughed up, just as in syphilis the virus is secreted and 
not washed off." And again: "From any chancre, plaque, gumma, or other 
deposit of syphilis, reabsorption may take place at any time, and reinfection 
with syphilis; or, better, reappearance of external signs. So, from any case- 
ous nodule, wherein the tuberculous virus is locked up in temporary inno- 
cence, absorption may take place under favoring circumstances, and a new 
outbreak of tuberculous symptoms appear, the quantity of virus thus set free 
determining, to a great extent, perhaps, the virulence of the symptoms. 
While the virus is thus locked up, the disease is latent; when set free, it is 
manifest." Wynne Foot savs: "Tubercles are small-celled overgrowths of 



508 PRINCIPLES OF SURGERY. 

lymphatic tissue that have preserved such uniformity of size, color, and shape 
as to have long suggested the probability of their lymphatic origin." Wilson 
Fox regarded tubercle as an overgrowth or hyperplasia of lymphatic tissue 
resulting from irritation of the lymphatic elements. 

Savory, in speaking of the relation of scrofula to tubercle, remarks: 
"It appears to me that there is nothing sufficient to warrant the pathological 
distinction which it is now the fashion to make between scrofula and tuber- 
cle." And further: "Tubercle may be said to be the essential element of 
scrofula." According to Eokitansky, the most frequent seat of tubercle in 
children is in the lymphatic glands. Virchow maintained that scrofula con- 
stitutes the basis of tubercle, and that in man tuberculosis depends in gen- 
eral on scrofula. He asserts, further: "On account of the histological iden- 
tity of the scrofulous and tubercular new growths, it is often impossible, in 
a given tubercular lesion, to determine how much is inflammatory and how 
much is tubercular." From the above quotations it becomes apparent that 
nearly all of the older authors recognized, if not the identity, at least a close 
relationship between scrofula and tuberculosis. The identity of scrofula and 
tuberculosis was established, not upon anatomical or pathological researches, 
but was definitely settled by the discovery of the same cause in the local 
lesions of both. Clinical and experimental proof is accumulating rapidly, 
establishing the fact that heredity in the causation of tuberculosis often 
means direct transmission of tubercle bacilli from parents to child. Birch- 
Hirschfeld and Schmore have reported the case of a young woman who, 
early in her first pregnancy, presented signs of pulmonary phthisis, to which 
she succumbed in the seventh month. Immediately after the death of the 
mother the foetus was removed by Cgesarian section. Post-mortem revealed 
tuberculosis not only in the lungs, but also in other organs of the mother. 
Although the foetus had been alive shortly before the death of the mother, 
it was dead when removed. Careful examination of the foetus showed no 
macroscopical tubercular lesions. The surface of the abdomen was washed 
with a solution of bichloride of mercury and the cavity opened with steril- 
ized knives. Small fragments of the internal organs were implanted into the 
abdominal cavities of two guinea-pigs and a rabbit. One of the guinea-pigs 
died in fourteen days. The other was killed at the end of six weeks, and 
many tubercles were found in the peritoneal cavity. The rabbit lived for 
three months. On its death many tubercles were found in the liver and lung. 
Tubercle bacilli were found in the umbilicus and in the blood of the um- 
bilical vein of the foetus. The demonstration of any definite anatomical 
defect, hereditary or acquired, which acts as a predisposing cause to tuber- 
cular infection, has, so far, not succeeded. Only a few years ago Formad 
made some interesting studies concerning the histological structures of tis- 
sues that are known to be prone to tubercular infection, and he believed that 



TUBEECULAB A.BS1 ESS. 

the changes constantly found were such thai favored the arrest of migrating 

cells. It is more probable that the hereditary or acquired predisposition to 
tuberculosis, which must now be recognized as an important element in the 
causation of the disease, must be regared rather as a diminution of the power 
of resistance inherent in the tissues to the action of the specific microbic 
cause than any characteristic anatomical cell-defects. From a clinical stand- 
point, it is important to remember that in the causation of tuberculosis we 
must recognize a combination of etiological factors, viz.: (1) local or general 
conditions, resulting from hereditary or acquired causes, which diminish 
the resisting capacity of the tissues to the action of the bacillus of tuber- 
culosis, which must be regarded as the predisposing cause; and (2) the pres- 
ence in the tissues of the essential cause of the disease, — the bacillus of tu- 
berculosis. 

The predisposing cause can under no circumstances result in tuberculo- 
sis without action of the essential cause, and the bacillus of tuberculosis is 
most certain to produce its specific pathogenic effect in tissues debilitated 
by hereditary or acquired causes. The different avenues through which in- 
fection takes place will be referred to in the further discussion of the sub- 
ject which heads this chapter. 

TUBERCULAB ABSCESS. 

Pathological Anatomy. — The effect of the bacillus of tuberculosis on 
the tissue is to produce a chronic inflammation, which invariably results in 
the production of granulation-tissue. The embryonal cells furnish, as it 
were, a wall of protection for the surrounding healthy tissue. The charac- 
teristic pathological feature of every tubercular product consists in the tend- 
ency of the cells of which it is composed to undergo early degenerative 
changes, which are caused by local anaemia and the specific chemical action 
of the toxins of the tubercle bacilli, and consist in coagulation-necrosis, 
caseation, and liquefaction of the cheesy material into an emulsion, which 
has always been regarded as pus until recent investigations have shown that 
it is simply the product of retrograde tissue-metamorphosis, and not true pus. 
I believe that it can now be considered as a settled fact that the bacillus of 
tuberculosis is not a pyogenic microbe, and that, in the absence of other 
microbes, it produces a specific form of chronic inflammation, which in- 
variably terminates in the formation of granulation-tissue; and that, when 
true suppuration takes place in the tubercular product, it occurs in conse- 
quence of secondary infection with pus-microbes. The so-called tubercular, 
or cold, abscess contains a fluid which macroscopically resembles pus, but 
which, when examined under the microscope, shows none of its histological 
elements. If the bacillus of tuberculosis meet with sufficient resistance on 
the part of the surrounding tissues, it finally exhausts the nutrient material 



510 PRINCIPLES OF SURGERY. 

in the granulations and dies, or remains -in a latent condition; the granula- 
tion-material is converted into cicatricial tissue and the local lesion is cured. 
The cases in which the tubercular product is removed by cicatrization ter- 
minate most frequently in spontaneous cure. If, on the other hand, bacilli 
in sufficient number are present to destroy the granulation-cells, coagulation- 
necrosis, caseation, and liquefaction of the infected tissue take place; a spon- 
taneous cure is still possible if a part of the fluid portion is absorbed and the 
solid debris becomes encapsulated. The same favorable termination is ex- 
pedited under similar circumstances if the primary lesion has healed and 
the inflammatory product is removed by operative interference under the 
strictest antiseptic precautions, or if, at the same time, the primary focus 
can be completely removed by extending the operation to the primary lesion. 
Secondary infection of a tubercular product with pus-microbes without a 
direct infection-atrium is possible, and if the primary lesion is located in an 
unimportant organ, and in such a place where the inflammatory product 
can be early reached or can be discharged spontaneously, a cure is often 
effected, as the suppurative inflammation may destroy all of the tissues in- 
habited by the bacillus, and the whole nidus, with the microbes it contains, 
is eliminated permanently from the body. Such a course is not infrequently 
observed in cases of tuberculosis of the lymphatic glands of the neck. If, 
however, the tubercular process affect important organs or parts deeply 
located with extensive infection of tissue, and secondary infection with 
pus-microbes take place, then the patient incurs the danger of septic infec- 
tion and local and general dissemination of the tubercular process from the 
breaking down of the protective wall of granulation-tissue. That the bacilli 
do not grow in a tubercular abscess has been definitely settled by Schleg- 
tendal. He examined 520 specimens of fluid from tubercular abscesses, and 
found bacilli present in only 75 per cent. Garre has also made an extended 
series of observations to ascertain the presence of the bacillus in cold ab- 
scesses. According to this author, many tubercular ulcerations and abscesses 
are the result of a mixed infection, as has been claimed by Hoffa for some 
cases of empyema complicating pulmonary or pleural tuberculosis. In cold 
abscesses, and in the liquefied cheesy material of tubercular cavities in bone, 
no pus-microbes could be found; not even in cases that pursued a rapid 
course. Cultivations of such material remained sterile, while inoculations 
produced t}'pical tuberculosis. Such specimens, examined under the micro- 
scope, showed none of the morphological elements of pus, but were seen to 
consist of an emulsion composed of fat-globules and detritus of broken-down 
tissue suspended in serum. Garre believes it is possible that, in many cases 
of suppuration following in the course of a tubercular process, pus is the 
result of a mixed infection, and that the pus-microbes disappear before the 
examination is made. 



TUBERCULAB A.BSCESS. 511 

Tavel has examined the inflammatory product of 40 cases in which a 
positive or at leasl probable diagnosis of tuberculosis was made, before op- 
eration, for evidences of mixed infection, by means of microscopical exam- 
ination of stained preparations under the microscope, cultivation and inocu- 
lative experiments. In 30 he found the tubercle bacillus exclusively, in 5 
tubercle bacilli and pus-microbes; the latter, however, had no hamiatogenic 
source, as their entrance into the tubercular focus through a communication 
between it and the internal or external surface of the body could be traced. 
In the last 5 cases he found no tubercle bacilli, but a mono-infection with 
pus-microbes which had produced a lesion resembling tuberculosis. He be- 
lieves, with Garre, that tubercular abscesses are caused exclusively by tuber- 
cle bacilli, but he assigns to these pyogenic properties. He maintains that 
the chemical products of the tubercle bacillus transforms leucocytes and 
embryonal cells from the fixed tissue-cells into pus-corpuscles, which, how- 
ever, show an earlier tendency to fatty degeneration and granular degenera- 
tion than pus-corpuscles in the pus of acute abscesses. 

Prudden and Hodenpyl killed tubercle bacilli by prolonged boiling, 
and still found them markedly chemotactic. When introduced in consider- 
able number into the subcutaneous tissue, or into the pleural or abdominal 
cavities, they are distinctly pyogenic, causing aseptic localized suppuration. 
Under these conditions they are capable, moreover, of stimulating the tis- 
sues about the suppurative foci to the development of a new T tissue closely 
resembling the diffuse tubercle tissue induced by the living germs, but this 
tissue manifests no tendency to caseation. 

The walls of the tubercular cavity contain the typical- structure of the 
tubercular lesion and the primary and essential cause of the inflammation: 
the bacillus tuberculosis. The infection follows the migration of the ab- 
scess in whatever direction that may take place. If an additional infection 
from without take place, following either a spontaneous discharge or after 
incision, the superficial granulations are destroyed by the suppurative process 
which is initiated, exposing the patient to the additional risks of septic in- 
fection and a more rapid local and general dissemination of the tubercular 
process. 

Symptoms and Diagnosis. — The tubercular abscess is called a cold ab- 
scess because it lacks the characteristic clinical phenomena which attend 
the development of an acute or hot abscess. There is but little, if any, rise 
of the local temperature, and, unless the abscess has reached the skin, the 
surface looks rather preternaturally pale than red, and the abscess itself is 
always painless and not tender on pressure. The pain, if present, is referred 
to the primary seat of the tubercular inflammation. Fluctuation is usually 
w r ell marked, as the tissues around the abscess are not much infiltrated. The 
most important clinical feature of a cold abscess is its tendency to wander 



512 PRINCIPLES OF SURGERY. 

from the place where it originated to distant localities by gravitation; hence 
the name given to it by German writers: Serikung sabs cess. Thus, in tuber- 
cular spondylitis the abscess may appear in the lumbar region, and is then 
called lumbar abscess; it may follow the iliac muscle and appear in one of 
the iliac regions, and is then called iliac abscess; or, finally, it may follow the 
psoas muscle and appear above or below Poupart's ligament, when it con- 
stitutes a psoas abscess. 

In tuberculosis of the hip- joint the abscess appears posteriorly under- 
neath the gluteal muscles, if perforation of the capsule in this direction take 
place; or it appears anteriorly a considerable distance below the hip-joint, if 
perforation of the capsule take place in an opposite direction. As the con- 
tents of the abscess carry the original cause of the disease, infection of the 
tissues takes place along the whole course of the abscess, which is always 
lined with infected granulation-tissue. Although the primary cause of a 
tubercular abscess is most frequently a tuberculosis of a joint or bone, it can 




Fig. 179. — Membrane Lining Tubercular Abscess. (Landerer.) 

also develop in the course of any localized form of tuberculosis, and it is 
quite frequently met in the course of tuberculosis of the lymphatic glands. 
The diagnosis must be made with special reference to the nature and loca- 
tion of the primary lesion. In tuberculosis of the spine the fixed pain in the 
region of the affected vertebrae, radiating from here in the direction of the 
nerves on each side, is an important symptom, and this symptom is always 
aggravated by flexion and ameliorated by extension of the spine. In coxitis 
the pain in the beginning of the disease is usually referred to the inner aspect 
of the knee-joint, but is always increased by motion in the hip-joint. In 
cold abscess, caused by glandular tuberculosis, the clinical history will point 
to a chronic inflammation of the glands which preceded the formation of 
the abscess. As soon as the abscess reaches the skin that structure becomes 
inflamed, livid, and more and more attenuated by pressure and inflammation, 
until spontaneous perforation takes place at a point subjected to greatest 
pressure. If a tubercular product become the seat of a secondary infection 
with pus-microbes, the subsequent symptoms, local and general, are those of 



TTTBEBOULAB A.BSOESS. 513 

suppurative inflammation. The temperature, which was normal, or nearly 
so. increases and presents the daily curves indicative of suppuration, while 
the abscess, which lias been painless heretofore, becomes painful and tender 
on pressure; in fact, a chronic inflammation has been supplanted by an acute 
one, with a corresponding change of the clinical picture. If any doubt re- 
main as to the character of the swelling and the nature of its contents, this 
can be dispelled at once by resorting to an exploratory puncture. In cold 
abscess the fluid removed presents the appearance of serum in which minute 
particles of broken-down tissues are suspended, while in an abscess caused 
by a mixed infection it presents the macroscopical and microscopical appear- 
ance of pus. 

Prognosis. — The danger attending tubercular abscess must be estimated 
exclusively by the extent and location of the primary disease and the pres- 
ence or absence of tuberculosis in other organs. If the general health re- 
main unimpaired, even an extensive local tubercular disease may be amen- 
able to a spontaneous cure or successful surgical treatment. On the other 
hand, a tubercular abscess developing in the course of an insignificant and 
unimportant local lesion occurring in an anaemic person, the subject of in- 
cipient multiple foci in different organs, must be regarded as a formidable 
condition, with little or no prospects of a favorable termination. I liave 
learned to regard pronounced anaemia as an unfavorable symptom in the dif- 
ferent forms of surgical tuberculosis, as it is often an expression that general 
infection has occurred. Another important matter to be taken into consid- 
eration, in making a prognosis in cases where general infection can be ex- 
cluded, is the possibility of eradicating the primary lesion by operative in- 
terference. Where this can be done, the chances of successful treatment of 
the local disease are much better; at the same time, the removal of all the 
infected tissues is the best guarantee against general infection. Other things 
being equal, the prognosis is better in patients without an hereditary history 
of tuberculosis, and in young persons than those advanced in years. 

Treatment. — The surgical treatment of large tubercular abscesses is 
always fraught with danger from the fact that, even if conducted under 
strict antiseptic precautions, it is not always possible to prevent infection 
with pus-microbes. Large tubercular abscesses were a u nole me tangere" to 
the older surgeons, as it was well known evacuation by incision would be fol- 
lowed within a few days by hectic fever, profuse sweating, diarrhoea, and 
other symptoms of septic infection. The early advocates of the antiseptic 
treatment hoped that the time had come when the surgeon had it in his 
power to prevent septic infection during the operation by resorting to the 
necessary antiseptic precautions, and to maintain an aseptic condition 
throughout the after-treatment under an efficient antiseptic hygroscopic 
occlusive dressing. If we remember that in cases where the abscess orig- 



514 PRINCIPLES OF SURGERY. 

inated from a primary lesion inaccessible to direct treatment it may require 
months for the healing process to be completed, it is not surprising that even 
the strictest aseptic precautions in the hands of the ablest surgeons have 
often failed in protecting the abscess-cavity against septic infection for such 
a long time. 

In a number of tubercular abscesses originating from a tubercular focus 
in the vertebrae, in the hip- and knee- joints, I have succeeded in preventing 
infection, and the patients were cured after several months of the most 
careful and watchful treatment; but in a greater number of cases infection 
occurred at the time of operation, or weeks or months later during change 
of the dressing, or in consequence of a slipping of the dressing. In abscesses 
in the gluteal or inguinal regions, especially in children treated by incision 
and drainage, it is almost next to impossible to maintain an aseptic condi- 
tion for weeks and months, and the most careful and laborious efforts in 
this direction will often result in failure. 

(a) Evacuation by Tapping followed by Antiseptic Irrigation and 
Subcutaneous Iodoformization. — The frequency with which failures have 
occurred after incision and drainage, in the hands of the most enthusiastic 
followers of the antiseptic treatment, has again roused the fear of surgeons 
in attacking large tubercular abscesses by incision and drainage, and the sub- 
cutaneous evacuation with subsequent disinfection of the abscess-cavity has 
again come into favor. That iodoform exerts an inhibitory effect on the 
growth of the bacillus of tuberculosis is now generally accepted. Its use 
in the treatment of tubercular affections is almost universal. It has been 
extensively used for injection into tubercular abscess, after evacuation by 
tapping, since Bruns advocated this treatment in 1887. It was first used dis- 
solved in ether in the proportion of 1 part to 20. The ethereal solution has 
the advantage of bringing the drug in contact with every part of the in- 
terior of the cavity by the distension which takes place from the expansion 
of the ether when exposed to the body-temperature, but the injection is 
usually followed by considerable pain. Bruns used a suspension of iodoform 
in glycerin and alcohol. Eecently the following formula was suggested by 
Krause : — 

Iodoformi subt. pulveris 50.0 

Mucil. gummi arab 23.0 

Glycerini 83.0 

Aquae destillatae q. s. ad 500.0 

(Ten-per-cent. iodoform mixture.) 

A safer and equally efficient preparation is a simple 10-per-cent. mixt- 
ure of iodoform in glycerin, which has been used for a number of years with 
such marked success in the surgical clinic of Eush Medical College, Chicago. 
The emulsion is sterilized by boiling. 

The evacuation of the abscess is to be done with an ordinarv trocar 



TUBEBCULAB &B8< ESS. 515 

under strict aseptic precautions. The Burface of the abscess is thoroughly 
disinfected in the usual manner, and the instrument rendered aseptic by 
boiling in soda solution. The trocar is inserted in Buch a manner that a track, 
at least an inch in length, is made underneath the skin before the instrument 
is plunged into the abscess-cavity, in order to make the wound, after the re- 
moval of the instrument, as nearly as possible subcutaneous. As tubercular 
abscesses usually contain shreds of dead connective tissue, fragments of fibrin, 
and masses of broken-down granulation-tissue, the evacuation is often at- 
tended by a considerable difficulty, as these substances block the opening of 
the instrument and thus prevent evacuation. The simplest procedure to 
overcome these difficulties is to introduce through the cannula a small hook 
made by bending an aseptic wire, and to extract with it any substance which 
interferes with the escape of the fluid contents. Gentle, uniform pressure 
is of great value in expediting the escape of the contents and preventing the 
entrance of air. Iodof ormization of the abscess-cavity is not to be done until 
complete evacuation of solid detached particles has been effected by means 
of irrigation with a 3-per-cent. solution of boric acid. This can be readily 
done with the injection-syringe here illustrated. A sufficient quantity of 
fluid is allowed to flow into the cavity until this is distended as much as 
before the evacuation of the fluid, when, by gentle pressure, it is forced out 
through the cannula. By filling and emptying the cavity alternately in this 
manner a requisite number of times, complete evacuation of the fluid and 
loose solid contents is effected, and the cavity is now ready for iodoformiza- 
tion. The iodoform injection is made with the same syringe. "Whatever 
formula for the solution is selected, not more than half a drachm of the 
iodoform should be injected at the first time, and in children even less. If 
this dose does not produce any unpleasant symptoms, it may be increased 
the next time the operation is repeated. There seems to be very slight dan- 
ger of iodoform intoxication, not even a symptom of this being observed in 
109 cases thus treated by Bruns, of Tubingen. If the ethereal solution is 
used, the iodoform will become diffused over the entire inner surface of the 
abscess-cavity; but, if a non-evaporating medium for the mixture is used, 
this must be done by gently kneading and rubbing the parts over the abscess 
after the cannula is withdrawn. The injection containing the iodoform is, of 
course, intended to remain in the cavity. The puncture in the skin is closed 
with collodium, and the walls of the abscess are put in as close contact as pos- 
sible by compress and bandage. Absolute rest is to be enforced for some time 
by splints or confinement in bed, according to the location of the abscess. The 
operation is to be repeated in the course of a week, or as soon as the abscess- 
cavity has partially refilled. The treatment of tubercular abscesses by sub- 
cutaneous evacuation, with subsequent iodoformization, should be adopted 
and repeated, from time to time, in all cases where the primary lesion is in- 



516 



PRINCIPLES OF SURGERY 



accessible to radical surgical treatment, and may yield good results in cases 
which heretofore had been subjected to heroic surgical treatment from the 
beginning. It may also prove useful as a preparatory treatment in cases 
which subsequently require operative interference. If the iodoform prove 
beneficial, seldom more than three injections are necessary; the most re- 
liable sign of its curative effect is increased viscidity of the contents of the 
abscess at each successive tapping. Iodoform has no curative influence in 
tubercular affections complicated by mixed infection with pus-microbes. 
Lannelongue makes use of a 10-per-cent. solution of chloride of zinc 




Fig. 180. — Senn's Injection-syringe. 



in the treatment of accessible tubercular affections. The injection is made 
not into, but around, the tubercular focus. Under strict aseptic precautions 
with an ordinary hypodermic syringe from 5 to 15 drops of 10-per-cent. solu- 
tion are injected at different points into the periphery of the tubercular affec- 
tion. The reaction is very prompt and often intense. In well-selected cases 
this treatment yields excellent results. It is of little value after abscesses 
have formed. Ziematsky made use of this solution in -40 cases of bone tuber- 
culosis with very satisfactory results. 

(b) Incision and Removal of Primary Focus. — In all cases where the 



TUBER01 I. \i: ABSCESS. 517 

iodoform iron t hum it is inapplicable or lias failed, and where, from the ana- 
tomical location o( the primary Lesion, it is possible to remove the tuber- 
cular product by operative interference, and the patient is free from other 
tubercular affections, a radical operation is absolutely indicated. In such 
cases the abscess-cavity is laid freely open in a direction which will secure 
most ready access to its interior with least injury to surrounding parts. 
After the abscess has been opened its contents are washed away by irrigat- 
ing with an aqueous solution of iodine, after which the granulations lining 
the cavity are scraped out with a sharp spoon and the primary lesion is 
removed in a similar manner. In dealing with such cavities it is impor- 
tant not to forget that the granulations contain tubercle bacilli, and, if 
they are not thoroughly removed, the principal object of the operation — 
removal of the primary cause — has not been accomplished, and a return 
of the disease is to be expected. If the abscess communicate with a 
primary focus in a bone, it is advisable to resort to ignipuncture of the 
bone after the cavity has been cleared of the granulations with the sharp 
spoon. The w<ound is then iodoformized and closed in the usual manner, 
leaving only a small opening at the most dependent point for drainage. 
The scraped surfaces are now in the same conditions for primary union 
as a recent aseptic wound, and, if kept in accurate apposition by the anti- 
septic dressing, which answers at the same time the purpose of a compress, 
primary union throughout is frequently obtained. Abscesses which have 
opened spontaneously, or during the treatment of which infection has 
occurred, must be treated on the same principles as acute abscesses. As 
far as can be done, the suppurating granulations should be removed with 
the sharp spoon and efficient tubular drainage established, and by fre- 
quent antiseptic irrigations an attempt is made to prevent septic infection. 
Landerer has recently called, attention to the value of balsam of Peru in 
the treatment of tubercular affections. He claims that this drug acts 
beneficially by stimulating the tissues to renewed activity, thus neu- 
tralizing, at least to a certain degree, the pathogenic effect of the bacilli. 
The late Dr. Sayre, of New York, has used this remedy for more than thirty 
years in the treatment of tubercular joints, and his results have certainly been 
extremely satisfactory. In the treatment of open, suppurating, tubercular 
cavities, the balsam of Peru should be tried as a local application. As 
a fluid for irrigation under the same circumstances nothing can surpass 
the efficacy of a strong aqueous solution of tincture of iodine or a 1-per-cent. 
solution of trichloride of iodine. 

(c) General Treatment. — Patients suffering from suppurating tuber- 
cular cavities require nutritious food, ale, porter, or some of the sub- 
stantial wines; out-door air will often prove the best tonic. Change of 
residence to the sea-shore or some mountain resort has often been known 



518 PRINCIPLES OF SURGERY. 

to effect a cure when recovery was despaired of as long as the patients 
lived in localities less favorably located. In the way of medication the 
treatment must be purely symptomatic. The prolonged use of 5-drop doses 
of guaiacol has a decidedly beneficial effect in the treatment of all forms 
of tuberculosis. Appetite is restored by the use of bitter tonics; anaemia 
is treated by the administration of some mild preparation of iron, as the 
syrup of iodide of iron, tincture of chloride of iron, albuminate of iron, or 
citrate of iron. If codliver-oil is given it should be administered pure, 
and not in emulsion, and never upon an empty stomach. The pale Nor- 
wegian oil is the best. The best time to give the oil, without disturbing 
the digestion, is an hour or an hour and a half after each meal, in doses 
of from a teaspoonful to a tablespoonful, according to the condition of 
the digestion and the age of the patient. 

TUBERCULOSIS OF THE MIDDLE EAR. 

That an ordinary otitis media with perforation of the tympanum 
may occasionally be transformed into a tubercular lesion by the entrance 
of tubercle bacilli there can be no doubt. A number of cases of primary 
tuberculosis of the middle ear have been reported and several cases have 
come under the personal observation of the writer. Habermann has in- 
vestigated this subject by examining, post-mortem, 18 tubercular subjects, 
in whom either otorrhoea or deafness, without active discharge, had been 
observed during life, and in 9 of these he could demonstrate the presence 
of tubercular lesions in the auditory canal. In 1 case he found, in the left 
auditory apparatus, tuberculosis of the entire middle ear where the tym- 
panum was intact. In another tubercular subject, a man 38 years of age, in 
whom tuberculosis of the ear was observed a year and a half before death, 
the post-mortem revealed extensive tuberculosis of the cochlea, in the 
internal auditory canal, and in the superior semicircular canal, while the 
other semicircular canals and the vestibule were destroyed by caries. 
Barnich describes two forms of tuberculosis of the middle ear: acute and 
chronic. The former is of rare occurrence, while the latter is very com- 
mon. In the second class of cases infection occurs most frequently from 
the naso-pharynx through the Eustachian tube. Extension of a tubercular 
otitis media to the mastoid cells is a very common and serious complica- 
tion. Infection with the bacillus tuberculosis of granulations in the 
middle ear through a perforation in the tympanum can occur in persons 
otherwise in perfect health. The diagnosis in such cases can be readily 
made by removing fragments of granulation-tissue for microscopical ex- 
amination. If they are found to contain tubercle bacilli a positive diag- 
nosis has been made, and no time should be lost in resorting to a radical 
operation. The removal of the infected granulations with a sharp spoon, 



11 BERCULOSIS OF THE IMS. 519 

followed by irrigation with a warm, 3-per-cent. solution of boric acid and 
iodoformization of the cavity arc the measures to be employed in removing 
the infected focus and in preventing extension of the disease into other 
parts of the ear, the mastoid cells, or the meninges of the brain. Airol is 
another very valuable local remedy in such cases. In operations on the 
mastoid for tuberculosis great care is necessary to avoid injuring the facial 
nerve. The author has seen a number of cases in which permanent facial 
paralysis followed the operation — one case in his own practice. 

TUBERCULOSIS OF THE IRIS. 

Inoculations of the anterior chamber of the eye with tubercular ma- 
terial have shown the extreme susceptibility of the iris to tubercular 
infection. That this structure should occasionally become the seat of 
primary infection is evident from a case reported by Griffith. The patient 
was a female child 7 months old. The eye had been affected for one 
month; there was an enlarged gland in the neck on the same side, but 
there were no other physical signs of tubercle; no history of heredity. A 
yellowish nodule grew from the periphery of the iris of the right eye, 
and numerous millet-seed-like bodies from its surface; the pupil was 
closed, but there was no acute inflammation. The local disease increased 
rapidly in extent. The eye was enucleated after three weeks' treatment. 
The disease was found to be confined to the iris and ciliary body. Under 
the microscope the new growth showed the characteristic structure of 
tubercle. In 32 recorded cases, in which microscopical and bacteriological 
tests left no doubt as to the tubercular nature of the disease, only 1 eye 
was affected in 29. The average age of the patients was 12 years; young- 
est, 4 months; oldest, 51 years. In 10 cases bacilli were searched for, but 
only found in -1; in 1 of the remaining 6 cases, however, the inoculation 
test was successful. A number of patients recovered completely and per- 
manently after enucleation. 

If the tubercle is located on the anterior surface of the iris, a diag- 
nosis can usually be made without much difficulty at an early stage, as 
the inflammatory product can be seen and carefully examined through the 
transparent cornea. If some doubt exist at first regarding the nature of 
the swelling, this is soon set aside by the progress of the disease. The 
primary nodule soon becomes surrounded and covered by an eruption of 
miliary tubercles. The disease here, as elsewhere, shows its characteristic 
clinical feature: progressive extension, affecting all the structures con- 
tiguous to or continuous with the part primarily affected, irrespective of 
their anatomical structure. Glandular infection on the same side is an 
early and quite constant occurrence. Even if the disease is correctly 
diagnosticated at an early stage, complete removal by iridectomy as a cura- 



520 PRINCIPLES OF SURGERY. 

live measure is impossible, as parts of the iris which present a perfectly nor- 
mal appearance may already be infected and lead to an almost certain recur- 
rence of the disease. Enucleation of the affected eye is only justifiable if the 
disease affect only one eye, and if the surgeon can satisfy himself that the 
patient is not suffering at the same time from tuberculosis in other organs 
inaccessible to successful surgical treatment. 

TUBERCULOSIS OF THE SKIX. 

Xearly all forms of primary tuberculosis of the skin, as far as we know, 
are the result of direct inoculation with tubercle bacilli. Considering the 
frequency with which abrasions occur in the exposed portion of the skin, and 
the innumerable sources of infection with the virus of tuberculosis, it is some- 
what strange that primary tubercular lesions of the skin are not of more fre- 
quent occurrence. Baumgarten believes that this is due to the slow growth 
of the bacillus and the dense structure of the deeper portions of the skin: 
conditions which enable the superficial wound to heal before the tubercle 
bacilli have penetrated the tissues to a sufficient depth. Considerable con- 
fusion exists at the present time in reference to the nomenclature of 
primary tubercular affections of the skin. We find descriptions of what 
is called tuberculosis of the skin, tuberculosis verrucosa cutis, and lupus, 
all of which affections have been proved to be tubercular in their origin 
and manifesting the same clinical tendencies. It is time that these imma- 
terial and unimportant distinctions should be set aside, and these different 
affections should be included under one head, as primary tuberculosis of 
the skin, since all of them present the same histological structure, and all 
are caused by direct inoculation with tubercle bacilli. 

Eiehl and Paltauf have described an affection of the skin, under the 
name of tuberculosis verrucosa cutis, in which the bacillus of tuberculosis 
is constantly found, and which they attributed to local infection, because 
all of the patients they examined were persons handling animal products. 
Eiehl has also shown the tubercular nature of papillomatous affections 
occurring upon the hands of pathological anatomists by finding the bacil- 
lus in the tissues. 

Anatomical and Clinical Proofs of the Tubercular Nature of Lupus. — 
Lupus vulgaris, and probably the other varieties of this affection of the 
skin, are nothing more nor less than cases of cutaneous inoculation- 
tuberculosis. It is well known that lupus occurs most frequently in parts 
of the body most exposed to injury and infection; that is, in the skin 
not protected by the hair or clothing. Lupus attacks most frequently the 
nose, face, eyelids, ears, and hands: localities where abrasions occur most 
frequently, and parts upon which floating microbes are too liable to be- 
come deposited, and where direct inoculation with soiled hands, handker- 



DUBEEOULOSia OF THE SKIN. 521 

chiefs, and towels is most likely to occur. I shall quote from a number of 
reliable authorities at sullieient Length to prove that lupus and tuberculo- 
sis are identical affections. From a clinical stand-point Hebra brought 
the different varieties of lupus under one common head. He separated it 
entirely from syphilis, but otherwise did little to fix its pathological signifi- 
eance. He adopted the classification of Fuchs and the older French and 
English authors, who taught that it was one of the manifestations of 
scrofula, and that anatomically it was composed of granulation-tissue. 

Virchow classified it with the granulomata, but denied its identity 
with scrofula. Eindfleisch described it as a proliferation of epithelial 
cells: as a sort of phthisis cutanea. Hueter, who, in his pathological views, 
was generally far ahead of his time, affirmed that it was a form of fungous 
inflammation, the specific cause of which, when introduced into the organ- 
ism, produced miliary tuberculosis. Volkmann included it among the 
affections which anatomically are represented by granulation-tissue. 
Friedlander was the first to take a positive stand in asserting that lupus 
is a tubercular affection of the skin, and showed its histological identity 
with other recognized forms of local tuberculosis. He demonstrated the 
presence of miliary tubercles in it. The absence of caseation in lupus, 
which was regarded by some authors, among them Baumgarten, as an 
evidence of its non-tubercular character, has been explained by Schuller 
as being due to the soil present in and around the nodules. He also calls 
attention to the fact that Cohnheim and Thoma have seen caseous foci 
in lupus, and consequently asserts that the absence of caseation is no 
proof of the non- tubercular nature of lupus. 

Xeisser accepts fully and pleads strongly in favor of the tubercular 
nature of lupus. Rassdnitz collected 209 cases of lupus, and found that in 
30 per cent, of all the cases it was associated with other evidences of 
tuberculosis. He placed, also, great importance on the observations that 
lupus is prone to develop in the scar left after healing of a localized tuber- 
culosis in lymphatic glands, and that lupus is often observed upon the 
nose or eyelids in cases of chronic nasal or conjunctival catarrh. In 10 
to 15 per cent, of his cases lupus could be traced to hereditary predis- 
position. Demme observed miliary tuberculosis in 2 of his cases after 
scraping lupus. Pontoppidan asserted that, in his experience, 50 to 75 
per cent, of patients suffering from lupus manifested additional evidences 
of tuberculosis. Quinquaud saw in 3 cases of lupus pulmonary tubercu- 
losis appear as a final cause of death. Of 38 cases that came to the per- 
sonal knowledge of Bessnier, 8 of them suffered from pulmonary phthisis. 
Of 2 patients treated by Aubert, 1 died of acute pulmonary tuberculosis 
and the other of tubercular pleuritis after scarification. 

Eenoward was able to ascertain the existence of pulmonary phthisis 



522 PRINCIPLES OF SURGERY. 

in 50 per cent, of his cases of lupus. Block met with tuberculosis in other 
organs, before or after the development of lupus, in 114 out of 144 cases. 
Bender examined 374 cases of lupus. In 159 of these an accurate history 
could not be obtained. In 99 of the latter number symptoms of other 
antecedent or coexisting tubercular lesions existed. In 77 of the cases 
tuberculosis in an etiological or clinical aspect was present. Leloir ob- 
served several cases in which, after years, a lupus of the face gave rise 
to a pseudoerysipelatous swelling of the face, which disappeared after a 
time, to be followed by swelling of the submaxillary lymphatic glands, 
which remained stationary. Soon after the affection of the lymphatic 
glands had appeared, febrile disturbances, gastric symptoms, and evi- 
dences of pulmonary infiltration followed. In all of these cases Leloir be- 
lieves that the virus of tuberculosis had left the primary location, and 
had migrated through the lymphatic vessels and glands into the lungs. 
In 10 out of his 17 cases the tubercular nature of lupus was clinically 
manifest. Sachs ascertained that, of 105 cases of lupus which he collected, 
in 86 per cent, the patients had coexisting tuberculosis in other parts of 
the body, or an hereditary predisposition to tuberculosis could be shown 
to exist. 

Experimental and Bacteriological Evidences of the Tubercular Nature 
of Lupus. — If the clinical and anatomical proofs which have been ad- 
vanced to establish the tubercular nature of lupus point unequivocally in 
that direction, the crucial test is furnished by the inoculation experiments 
and bacteriological investigations that have been made with the same 
object in view. Koch, in his paper on the etiology of tuberculosis, states 
that he produced a pure culture of the bacillus tuberculosis from a case of 
lupus which resembled, in every respect, the cultures obtained from recog- 
nized tuberculosis, and with the fifteenth generation from this source, 
one year after the first cultivation, he inoculated 5 guinea-pigs by sub- 
cutaneous injection and produced typical tuberculosis in all of them. 
Doutrelepont found in 7 cases of lupus the bacillus tuberculosis invariably 
present, in greater or less number, either within the cells or dispersed in 
small groups between them. He never found them in the interior of 
giant-cells, but in their immediate vicinity. In a second communication 
the same author reports 18 additional cases of lupus, in each of which the 
presence of the bacillus could be demonstrated in the tissues. Demme 
detected the bacillus in 6 cases of lupus. Pfeiffer found it in a case of 
lupus of the conjunctiva. Schuchardt and Krause discovered the bacillus 
in 3 cases of lupus affecting, respectively, the face, ears, and leg. In 
examinations made of 11 cases of lupus by Cornil and Leloir, and 4 by 
Koch, for the especial purpose of showing the identity of lupus and 
tuberculosis, the bacillus was found in everv instance. In the artificial 



TUBERCULOSIS OF THE skiv 523 

tuberculosis o( animals, produced by implantation of lupous tissue, the 
specific microbe was shown to exist by Pagensteeher, Pfeiffer, Koch, and 
Doutrelepont. To prove that lupus and tuberculosis are identical, it be- 
came accessary to furnish the necessary experimental proof, and to show 
the uniform presence of the bacillus of tuberculosis in the lupous tissue, 
all of which has been done with almost infallible positive results. The 
inoculation experiments with lupous tissue have already been referred to, 
and from them it can be learned that, with few exceptions, they were 
followed by positive results; that is to say, implantation of lupous tissue 
into subcutaneous tissue or the peritoneal cavity, in animals susceptible 
to tuberculosis, gave rise to local tuberculosis at the point of implantation 
and to dissemination of the process in a manner characteristic of tubercu- 
losis in man. A diffuse tuberculosis of the skin and mucous membranes, 
occurring as a sort of secondary localization in patients suffering from ad- 
vanced tuberculosis, has been recently described by Pantlen, Bizzozero, 
Baumgarten, Chiari, Hall, Janisch, Biehl, Vidal, and Finger. As such 
cases occur in consequence of auto'infection in persons debilitated by the 
ravages of the primary disease in the lungs, it is not surprising that the 
skin affection should extend more rapidly than in cases of primary tuber- 
culosis of the skin. 

Pathology and Morbid Anatomy. — As every case of tuberculosis of 
the skin is caused by the entrance of tubercle bacilli from without through 
some infection-atrium, the primary pathological changes occur at the 
point of inoculation. As soon as the bacilli reach the vascular layers of 
the skin, a nodule forms which contains the histological elements de- 
scribed in the section on the "Histology of Tubercle." By the formation 
of new nodules, a more diffuse cellular infiltration of the tissue between 
them, the lesion tends to spread, and, by confluence of the infiltrated por- 
tions, a dense and more or less extensive area of nodular infiltration may 
be formed. If the continuity of the epidermic layer of the skin has been 
restored after infection has occurred, and the cell-proliferation has been 
abundant, the swelling may resemble a papillomatous growth, and, on ac- 
count of the increased vascular supply, an excessive production and ex- 
foliation of epidermis over the infiltrated area occur. These are the cases 
of inoculation-tuberculosis which have been described as tuberculosis 
verrucosa cutis. The nodules undergo disintegration near the centre, and 
the epidermis at a corresponding point becomes macerated and detached, 
leaving at first a minute defect, which secretes a serous fluid. 

As soon as the underlying granulation-tissue has been exposed to in- 
fection from without, infection with pus-microbes occurs, and the destruc- 
tion of tissue is hastened by the suppurative inflammation which follows, 
as the granulation-cells are rapidly destroyed by the pus-microbes and 



524: PRINCIPLES OF SURGERY. 

their, toxins, and are eliminated as pus-corpuscles. Ulceration now takes 
the place of the papillomatous growths, and the defect increases in size 
as rapidly as granulation-tissue is produced by the action of the bacillus 
tuberculosis. Xew nodules are produced in the immediate vicinity of the 
ulcer, which are again dissolved by retrograde tissue-metamorphosis of its 
cellular constituents and purulent liquefaction. It is not uncommon to 
find, at some places, efforts at repair, and even partial cicatrization and 
epidermization : but the disease pursues its relentless course in other di- 
rections, and, after what appears as healthy new tissue, becomes again 
infected and the process of destruction is repeated. In some forms of 
tuberculosis of the skin the infection remains superficial, and only the 
more superficial portions of the skin undergo pathological changes charac- 
teristic of tuberculosis: while in other cases the process extends deeper 
and deeper, until muscles, fascia, and bone are destroyed by the disease, in 
the manner of its extension from tissue to tissue resembling, in this respect, 
the clinical behavior of malignant tumors. In this manner the whole nose, 
eyelids, and the greater portion of the face are frequently destroyed before 
the patient is relieved from his sufferings by a merciful death. Microscopical 
examination shows the lesions to consist in the formation of granulation- 
tissue, in which the typical structure and histological elements of tubercle 
can be readily recognized. Caseation is seldom found, probably on ac- 
count of the location of the tubercular product so near the surface of the 
skin, and also because the granulation-tissue soon becomes the seat of a 
secondary infection with microbes which prevent caseation. In most cases 
a well-marked reticulum is present between the new cells, and these are 
often grouped in masses around the blood-vessels. 

Symptoms and Diagnosis. — Tuberculosis of the skin is most frequently 
met with in middle-aged persons, but no age is exempt from it. as I have 
seen it in children 5 years of age and in persons far advanced in years. 
It attacks most frequently the nose, eyelid-, cheeks, ears, and hands, but 
it may also develop upon the different parts of the trunk. The disease 
commences in the form of a small, red, vascular nodule: is not painful 
nor tender on pressure. In the vicinity of this nodule new foci spring up, 
and by confluence may form a swelling of considerable size. To the touch 
these nodules impart rather a sensation of elasticity than hardness, and if 
the swelling is large in size an obscure sense of fluctuation may be felt. 
Before ulceration takes place the surface of the nodules is covered by a 
thickened epidermis, which can be scraped off in white scales. If no ulcer- 
ation take place (lupus non-cvedeus). the nodules may remain stationary 
in size for an indefinite period of time or undergo a spontaneous cure by 
cicatrization, during which the epithelioid cells are converted into con- 
nective tissue. Ulceration begins over the centre of the nodule, at a point 



Tl BEEOULOSIS or THE SKIN. 525 

whore the nutrition of the tissues is most impaired by pressure, and ex- 
tends from here toward the margins ol' the nodule, attacking the new 
nodules almost as fasl as they are formed [In pus exedens). Cicatrization 
and ulceration are often seen side by side. Dlceration is hastened by the 
secondary infection with pus-microbes, which invade the granulation- 
tissue in the margins of the nicer, occupying the tubercular zone. Repair 
by cicatrization and epidermization is more likely to occur if the infection 
remains superficial, but is usually entirely absent as soon as the tubercular 
process has extended beyond the limits of the skin. The differential diag- 
nosis as to tuberculosis of the skin, tertiary syphilis, and epithelioma is 
generally very difficult, and sometimes almost impossible. There is very 
little difference between the histological structure of a tubercle-nodule 
and a gumma, and the most experienced microscopist is liable to make a 
mistake if called upon to make a diagnosis exclusively by the use of the 
microscope. 

The history of the case is of the greatest importance in making a 
differential diagnosis between tuberculosis and syphilis. If the patient is 
positive that he never contracted syphilis, it is still possible that the 
lesion may be syphilitic, as the disease may have been inherited; if he 
give a history of primary and secondary syphilis, the affection may still 
be tubercular; but a straight history of tuberculosis or syphilis will go far 
in determining the nature of the local affection. If any doubt remain 
this can be cleared up by the use of the microscope, and, if this fail, in 
the course of five weeks, either by the effect produced by antisyphilitic 
treatment or the result of inoculation experiments made by implantation 
of fragments from the inflammatory product into the subcutaneous tissue 
in guinea-pigs. The microscopical examination of fragments of tissue re- 
moved for this purpose must have in view the detection of the bacillus 
of tuberculosis, which is constantly present hi tubercular tissue. The 
specimen must be prepared by double staining according to Ehrlich's 
method, and, if the affection is tubercular, the bacillus can be found by 
making a patient search for it; if it is syphilitic, it will, of course, be 
absent. The bacilli, however, may be so few that even a careful search 
of stained specimens may result negatively, and in such a case a positive 
diagnosis can often be made by observing the effects of a thorough anti- 
svphilitic treatment. For an adult, 1 / 30 grain of corrosive sublimate with 
15 grains of potassic iodide, dissolved in distilled water, is given four times 
a <j a y, — after each meal and at bed-time. If the lesion is syphilitic, a de- 
cided improvement will be observed in the course of two or three weeks; 
if tubercular, this treatment will make no decided impression on the local 
lesion. The most reliable diagnostic test in differentiating between tuber- 
culosis of the skin and a syphilitic lesion consists in removing, under aseptic 



526 PRINCIPLES OF BUBGEBY. 

precautions, a fragment of granulation-tissue the size of a small pea, and im- 
planting the same into the subcutaneous tissue of a guinea-pig. 

Tavel has been studying, in a systematic manner, the diagnostic value 
of implantations of tubercular material in animals, mainly guinea-pigs. He 
found that fragments of granulation-tissue, taken from a tubercular product 
and implanted into the subcutaneous connective tissue in the inguinal re- 
gion in guinea-pigs, invariably produces in this animal local, and later gen- 
eral, miliary tuberculosis, and death in from five to six weeks. The course 
of the disease thus artificially produced is typical; at the point of inocula- 
tion a hard nodule appears first, the result of traumatic response on the part 
of the tissues around the graft. Next, a lymphatic gland becomes enlarged 
in the immediate vicinity of the inoculation and in the direction of the lym- 
phatic stream. Often all of the inguinal glands are infected successively. 
At a later stage the axillary glands become affected. At the necropsy it was 
always observed that, of the internal organs, the spleen becomes affected 
first, then the liver and lungs: but before death is produced almost every 
organ is the seat of miliary nodules. TThen the differential diagnosis be- 
tween tuberculosis and syphilis cannot be made from a clinical study of the 
case or by the use of the microscope, inoculation experiments will always 
furnish the desired information in from three to six weeks. If the lesion is 
tubercular, the infected guinea-pig contracts the disease, and dies in from 
five to six weeks; if it is syphilitic, the implantation will prove harmless and 
the animal remains well. The differential diagnosis between tuberculosis 
of the skin and epithelioma must be based on the primary location of the 
pathological product and the character of the infiltration. Tuberculosis 
commences in the vascular portion of the skin; hence, the primary nodule is 
subepidermal; while epithelioma starts in the non-vascular epidermis and 
infiltrates the deeper layers of the skin later. The tubercular nodule is not 
hard, but somewhat elastic, to the touch. The carcinomatous infiltration 
feels almost as hard as cartilage, and forms a part of the epithelial layer of 
the skin from the beginning. A tubercular ulcer of the skin is covered with 
flabby granulations, and its margins, although infiltrated, do not feel as firm 
as the borders of an ulcerating epithelioma. Under the microscope the tu- 
bercle-nodule shows granulation-cells in the meshes of a delicate reticulum, 
while in a section of an epithelioma a well-marked alveolated reticulum can 
be seen, the meshes of which are occupied by embryonal epithelial cells ar- 
ranged in concentric layers. Another microscopical criterion is the absence 
of blood-vessels in tubercle-nodules, while carcinoma is a vascular structure. 

Prognosis. — Primary local tuberculosis of the skin may lead to gland- 
ular infection, and, after the last lymphatic filter has been passed, to gen- 
eral miliary tuberculosis. The tubercular product in exceptional cases be- 
comes the starting-point of carcinoma. The local extension of the tuber- 



CUBEBOULOSIS OF THE SKIN. 52*3 

eular process is subjecl to many variations. In some instance- the pi 
commences during early life, and remains stationary for twenty or more 
years, when it suddenly commences to extend very rapidly, destroying all 
of the tissues which come in its way, irrespective oi' their anatomical struct- 
ure. Tuberculosis of the lace, manifesting such a tendency to rapid exten- 
sion, may in a lew months destroy nearly all of the soft tissues and a con- 
siderate portion of the superficial bones, so that the head looks more like 
a skull than the head of a living being. In other instances the ulceration 
keeps extending, while at other points the healing process is progressing with 
equal speed. In such cases the massive scars are often productive of the 
most hideous deformities. Eecurrence of the disease in the scar-tissue is of 
common occurrence. The prognosis, as far as life is concerned, is favorable 
so long as the disease remains local and does not progress rapidly; while life 
is threatened as soon as regional infection through the lymphatic glands 
takes place, or when ulceration extends rapidly without any tendency to re- 
pair by cicatrization and epidermization. Tuberculosis of the skin without 
ulceration is a more benign form of the disease than when ulceration has 
occurred, as in the latter case the destructive process is hastened by second- 
ary infection with pus-microbes. 

Treatment. — About the only medicine that deserves any confidence in 
the treatment of tuberculosis of the skin is arsenic. This drug can be given 
in the form of Fowler's solution, in doses of from 3 to 10 drops after each 
meal, well diluted with water. It is best to commence with the smallest 
dose and add 1 drop every week until the physiological effect is produced, 
when the use of the medicine is not suspended, but the dose is diminished. 
To be of any use, the medicine has to be continued for weeks and months. 
If the patient is anaemic, it is combined with the tincture of chloride of iron, 
and, if the patient's appetite is poor, with one or more of the bitter tonics. 
If the patient is emaciated, pure codliver-oil can be given with good results 
an hour and a half after meals, in doses which will be tolerated by the 
stomach. If digestion is impaired this drug should be withheld. A well- 
selected, nutritious diet is indicated in all such cases, with plenty of out- 
door exercise. Salt-water baths invigorate the peripheral circulation, and 
consequently favor the limitation of the disease and the process of repair. 
The surgical treatment of tuberculosis of the skin is to be conducted upon 
the same principles as operations for the removal of malignant tumors. The 
use of caustics often does more harm than good. The great object of the local 
treatment is to remove every particle of the infected tissues, for if this is not 
done a recurrence is almost sure to take place. If the patient object to a 
radical operation, and the tubercular process has gone on to ulceration, all 
irritating applications should be avoided and the ulcer protected by a piece 
of lint spread with empl. hyrlrargyri or unguent, hydrargyri oxyd. albi. Bal- 



528 PRINCIPLES OF SURGERY. 

salm of Peru can also be used with benefit as a local application. If a radical 
operation is decided upon, this should be done preferably by excision. Ex- 
cision should be practiced exclusively in cases where the extent of the disease 
is limited. The incisions should be made some distance from the visible 
margins of the infiltration, in order to include tissues which, although pre- 
senting macroscopically a healthy appearance, may already be infected with 
bacilli, conveyed there by migrating leucocytes. The greatest care must be 
exercised in removing the deeper portions of the inflammatory product, as 
this may send down projections at different points which it becomes neces- 
sary to remove with the principal mass. 

Thiersch's method of restoring the excised skin places the surgeon in a 
position where he can excise an extensive area of integument, and yet obtain 
primary healing of the wound and perfect restoration of the skin under a 
single dressing. I have, on several occasions, removed tubercular foci from 
the face and temporal region the size of the palm of the hand, and, by cov- 
ering the defect at once with large skin-grafts, saw the whole healing process 
completed in two weeks, with almost perfect restoration of the lost tissues. 
In cases where the disease is too extensive for excision, removal of the in- 
fected granulations is attempted by the vigorous use of Yolkmann's sharp 
spoon. Skin-grafting can be done after curetting in the same manner as 
after excision, but the knife always leaves a better surface for skin-grafting 
than the sharp spoon. If, after either operation, the result is not perfect, 
and the tubercular process returns at one or more points, the granulations 
are again removed with the sharp spoon and the defect covered with skin- 
grafts. Tuberculosis without ulceration demands treatment by excision, 
while in the case of ulcerating nodules the choice lies between the knife and 
sharp spoon, and to the first preference should be given in all cases where 
excision can be done with a fair prospect of removing all of the infected 
tissues. The constitutional treatment should be continued for several 
months after the local lesion has apparently healed, as the disease is very 
liable to recur at the site of operation. The site of operation should be care- 
fully protected against injury a long time after the process of repair has 
been completed, in order to guard against a return of the disease, from local 
irritation j)reparing the soil for the pathogenic action of latent bacilli which 
may remain incorporated in the scar-tissue. 

In large defects of the skin caused by the disease and operation the 
surface can often be covered by a plastic operation, and, when this is pos- 
sible, it should be preferred to skin-grafting, as the results are much more 
satisfactory. 



CHAPTER XXI. 

Tl BERCULOSIS OF LYMPHATIC GLANDS AND PERITONEUM. 
Tl BERC1 LOSIS OF LYMPHATIC GLANDS. 

That most cases of chronic inflammation of the lymphatic glands are 
— in their origin, course, and final termination — instances of local tuber- 
culosis has been satisfactorily shown by clinical experience, microscopical 
examination, inoculation, and cultivation experiments. 

Manner of Infection and Dissemination of the Bacillus of Tuberculosis. 
— The tubercle bacilli enter the lymphatic circulation through some abrasion 
or pathological defect of the skin or mucous surface; any loss of continuity 
of surface may furnish the necessary portio invasionis for the entrance of 
the microbes from without. Tuberculosis of the cervical lymphatic glands 
occurs most frequently by infection through the tonsils, naso-pharynx, or 
diseased alveoli of the maxillary bones. De Mochowski found that the mu- 
cous membrane of the naso-pharynx is diseased in 21 out of 64 tubercular 
patients. Stark believes that carious teeth are the most common source of 
infection. Nicoll studied 500 cases of tuberculosis of the lymphatic glands 
of the neck and ascertained that the glands over the sheath of the large ves- 
sels on a level with the bifurcation of the carotid artery are generally first af- 
fected. In 70 per cent, of the cases the disease was bilateral. The author 
has seen a number of cases of tuberculosis of the axillary gland secondary 
to a similar affection of the glands of the neck; very rarely as a primary 
affection. The inguinal glands are occasionally involved primarily", and there 
is good reason to assume that infection takes place through the external 
genital organs. Tuberculosis of joints and bones seldom gives rise to glandu- 
lar tuberculosis. An interesting case of this kind came recently under my 
observation .in which progressive tubercular lymphadenitis of the left groin 
followed chronic tuberculosis of the knee-joint on the corresponding side 
(Fig. 181). In tubercular affections of the skin the point of inoculation 
becomes the centre of the primary nodule, because the bacilli are present in 
sufficient quantity and virulence to produce the necessary irritation; but in 
tuberculosis of the lymphatic glands the microbes enter the lymphatic chan- 
nels usually before they have caused any visible lesions at the point of en- 
trance. 

Volkmann found tubercle bacilli in the skin of an eczematous fore- 
arm, and it is probable that many cases of tuberculosis of the cervical glands 
in children are caused by the entrance of tubercle bacilli through an eczem- 
atous patch on the face, ear, or scalp. In perhaps 95 out of every 100 

34 (529) 



530 



PRINCIPLES OF SURGERY 



cases of tuberculosis of the lymphatic glands the disease attacks the glands 
of the neck, — as the scalp, face, and mouth are parts of the body most fre- 
quently the seat of slight injuries and superficial lesions, and also most ex- 
posed to tubercular infection. The lymphatic glands act as filters for the 
microbes which enter the body through the lymphatic channels. The patho- 
logical conditions which are produced in the interior of a lymphatic gland 
by the presence of pathogenic microorganisms are well calculated, for the 
time being at least, to limit the extension of the infection. The lymphad- 
enitis which is produced blocks the lymph-spaces with the products of a 
specific inflammation, which, temporarily at least, mechanically obstructs 




Fig. 1S1.— Tubercular Lymphadenitis following Tuberculosis of the Knee-joint. 



the way for the microbes toward the general circulation. Primary infection 
of a lymphatic gland by the bacillus of tuberculosis in many instances attacks 
different portions of the gland from the very beginning, as a number of in- 
dependent centres of tissue-proliferation are established around each mi- 
crobe, or around each colony of microbes arrested on their way throuo-h. the 
gland. These separate nodules soon become confluent and form a mass of 
considerable size, which soon implicates the entire parenchyma of the gland. 
Local dissemination of the bacillus of tuberculosis in the interior of the 
gland is accomplished by the assistance of the lymph-stream, as long as the 
microbes remain free, and through the medium of wandering cells as they 



ll BEKCULOSIS OF LYMPHATIC GLANDS. 531 

have become attached to or have 1 entered the protoplasm of the lymphoid 
corpuscles and leucocytes. 

Regional infection is not limited to the lymphatic glands, on the proxi- 
mal side of the primary focus, as during the course of the disease we often 
observe that lymph-glands become involved which are not in the direct 
course of the lymph-stream. As the bacillus of tuberculosis is non-motile, 
we vim only explain its transportation in a direction opposite the lymph- 
current by its conveyance in such a direction by migrating amoeboid cells. 
As the lymph-stream is impeded or perhaps completely arrested by the 
inflammatory product which has accumulated in the lymph-spaces, mi- 
gration of leucocytes in an opposite direction is easily explained. The 
usual course of infection along the lymphatic channels is, however, 
in the direction of the lymph-current. The course of the disease is 
almost characteristic. A lymphatic gland in the submaxillary or parotid 
region becomes enlarged, and from this centre the infection invades 
successively gland after gland, until the whole chain of lymphatics 
from the angle of the lower jaw to the clavicle has become involved. An- 
other interesting feature is observed in reference to the regional diffusion 
of the tubercular process, as the course of infection usually corresponds to 
the location of the gland first affected. If the infection has involved pri- 
marily one of the deep glands of the neck, the glands subsequently invaded 
belong to the deep lymphatics which follow the large blood-vessels of the 
neck. If, on the other hand, the primary depot is located in one of the 
superficial glands, the glands, which are being irrigated by the lymph that 
flows through and from the gland, become the seat of successive infection, 
showing again that regional infection usually takes place in the direction 
of the lymph-current. In extensive tuberculosis of the glands of the neck, 
the superficial and deep glands are affected at the same time, the infection 
from one set of vessels to the other being accomplished through the medium 
of communicating branches. As long as the infection has not extended along 
the entire length of the chain of lymphatic glands, the patient is protected 
against miliary tuberculosis; but as soon as the virus has passed all of the 
lymphatic filters it enters the general circulation, and diffuse miliary tuber- 
culosis follows as an inevitable result. 

Pathological Histology and Morbid Anatomy. — As soon as a sufficient 
number of bacilli has entered the parenchyma of a lymphatic gland, a karyo- 
kinetic process is initiated which involves the parenchyma-cells, the cells 
of the reticulum, and the endothelial cells. The proliferating tissue-cells 
produce epitheloid and giant cells, while the lymphoid elements are either 
the normal lymphoid corpuscles, which have remained unaffected by the 
inflammatory process, or leucocytes. As the number of bacilli present is 
not great, the process is a very slow one, and the inflammatory product un- 



DO'4 PRINCIPLES OF SURGERY. 

dergoes very gradually the characteristic degenerative changes. The en- 
trance of new bacilli from the infeetion-atriuni is prevented by the obstruc- 
tion in the lymph-spaces, caused by the accumulation within them of the 
products of inflammation, which arrests the lymphatic circulation in the 
afferent vessels of the gland, through which primarily the bacilli entered. 
The bacilli found in the tubercular gland are. therefore, derived from the 
multiplication of the bacilli which originally entered the gland from the 
primary infection-atrium. The cells that first undergo coagulation-necrosis 
are those in the centre of each nodule, for reasons which have been pre- 
viously mentioned. As the products of coagulation-necrosis do not furnish 
the necessary nutritive material for the growth of the bacillus, the microbes 
gradually disappear in the centre of the nodule, while they can still be found 
within and between the cells in the surrounding granulation-tissue. Cell- 
necrosis is followed by caseation, and by this time nearly all of the bacilli 
have disappeared, but inoculation experiments with cheesy material have 
shown that spores remain in an active condition, and capable of reproducing 
the disease in animals. The numerous nodules which appear, often almost 
simultaneously, in the interior of the same gland become confluent, and. in 
the course of time the entire parenchyma of the gland is destroyed, while the 
intact capsule of the organ still furnishes a wall of protection against infec- 
tion for the surrounding tissue. A single tubercular gland is seldom larger 
than a walnut, and the large masses found in the neck and other regions 
are composed of several glands so closely packed together as to give the ap- 
pearance of a single gland. When the capsule becomes infected, the same 
processes are initiated here as in the parenchyma of the gland: the con- 
nective tissue is transformed into granulation-tissue, which undergce- ::- 
agulation-necrosis and caseation in the same manner as the fixed tissue-cells 
of the parenchyma: and, finally, after perforation of the capsule has taken 
place, the inflammation extends to the paraglandular tissues, resulting in 
tubercular periadenitis. The cheesy material may dry and shrink and be- 
come inclosed by a capsule of dense connective tissue, resulting in calcifica- 
tion: or it undergoes liquefaction. If secondary infection with pus-microbes 
take place, — a not infrequent occurrence in tuberculosis of the glands of 
the neck, — an acute suppurative inflammation takes the place of the chronic 
process, and almost without exception results in a rapidly-spreading sup- 
purative periadenitis. The connective tissue surrounding the gland becomes 
swollen and cedematous and large abscesses form, which, on being incised, 
give exit to pus which resembles the pus of an ordinary phlegmonous in- 
flammation. The suppurative inflammation results in extensive detachment 
of the cheesy glands, which at this time can be readily enucleated by the 
finger. If, however, the abscess is simply incised, and the radical operation 
postponed for weeks or months, the removal of such glands is an exceedingly 



rUBEBOULOSIS OF LYMPHATIC GLANDS. 533 

difficult task, as the capsule of the gland will then be found intimately ad- 
herenl to the Burrounding tissues. 

Symptoms and Diagnosis. — Tuberculosis of the lymphatic glands occurs 
most frequently in persons between 15 and 30 years of age. The regions 
most frequently affected are the cervical, parotid, submaxillary, axillary, 
and inguinal. Tuberculosis of the parotid, submaxillary, and cervical lym- 
phatic glands is often preceded by eczema of the scalp, ears, or face, or by a 
catarrhal or tubercular inflammation of the mucous membrane lining the 
nose and pharynx. It is possible that in many of these cases the catarrhal 
inflammation creates the necessary infection-atrium for the entrance of the 
bacilli into the lymphatic channels; or, what is more probable, that which 
has been regarded as a catarrhal inflammation is, in reality, a mild tubercular 
inflammation that may disappear after infection of the lymphatic glands has 
occurred. In the region of the neck, the first glands affected are usually 
the submaxillary, or the glands just behind, in front, or below the external 
meatus. Progressive infection is the most characteristic clinical feature of 
tuberculosis of the lymphatic glands. Eegional infection, as has been stated, 
usually takes place by the extension of the disease from gland to gland, until 
the whole chain in a region has become affected. In a case far advanced, for 
instance, the glands first affected may be as large as a walnut; their size 
then gradually diminishes, so that those last infected may not be larger than 
a split pea. The degenerative changes are also most marked in the glands 
first affected; so that, while the primary foci show well-marked evidences of 
caseation, and caseation with liquefaction, the glands last infected still pre- 
sent a normal pinkish color. The number of glands affected in one region 
varies from one to twenty or more. If many glands are affected, the hyper- 
plastic inflammation in their periphery usually results in their becoming 
matted together into a dense nodular mass. With the exception of the neck, 
it is seldom that more than one anatomical region is affected. In the cervical 
region it is not uncommon to find the glands on both sides affected at the 
same time. The infected glands increase gradually in size; they are painless 
and not tender on pressure. At first they are movable, and appear loosely 
attached to the surrounding tissues. With the appearance of periadenitis 
the swelling rapidly increases in size, and the gland becomes fixed and im- 
movable. Liquefaction of the cheesy material is announced by softening 
and perceptible fluctuation. Secondary infection with pyogenic microbes 
is followed by phlegmonous inflammation in the capsules and in the con- 
nective tissue surrounding the affected glands. The course of the disease, 
so far as time is concerned, is extremely variable. The extension of the in- 
fection and the growth of the swellings may become arrested for months or 
years, when the disease may take a new start and pursue its typical course. 
I recollect the case of a woman, 45 years of age, who had an enlarged gland 



534 PRINCIPLES OF SURGERY. 

the size of a hazel-nut in the upper cervical region, which remained station- 
ary for twenty years, when the swelling rapidly increased in size; new glands 
became infected, and, when the glands were removed by operation, it was 
seen that the first gland was composed of a thickened capsule, distended to 
its utmost by inspissated cheesy material. The capsule showed evidences of 
recent tubercular inflammation, and small foci of caseation were detected in 
the glands that had recently become infected. "When a true suppuration 
takes place in a tubercular lymphatic gland, it does so in consequence of a 
secondary infection with pyogenic microorganisms. A spontaneous and per- 
manent cure is not infrequently effected by the substitution of an acute sup- 
purative process in place of the primary specific chronic inflammation, which 
destroys the entire soil of the bacillus tuberculosis and, at the same time, 
effects complete elimination of the bacilli through the discharge of the ab- 
scess. While tuberculosis of the lymphatic glands often stands in a direct 
causative relationship to and precedes general, diffuse, and pulmonary tuber- 
culosis, it is seldom observed as a secondary affection in the course of pulmo- 
nary tuberculosis. I have observed one case of tuberculosis of the lungs with 
secondary infection of the lymphatic glands. The patient was a woman, 50 
years of age, who had suffered for two years from well-marked typical tuber- 
culosis of the lungs, when the glands on both sides of the neck became in- 
fected, and continued to increase in number and in size until she died, six 
months later. Frankel reports an interesting case in which lymphatic and 
pulmonary tuberculosis developed almost simultaneously. The patient was 
a woman, 51 years of age, who had given birth to two children, their father 
being the subject of advanced tuberculosis, and both of whom died of tuber- 
culosis. She had been in perfect health until her 49th year, when she was 
attacked simultaneously with pulmonary and glandular tuberculosis, from 
the combined effects of which she died in a few months. In exceptional 
cases glandular tuberculosis pursues an acute course. Delafield reports an 
exceedingly interesting case of this kind. The disease commenced with en- 
largement of one of the cervical glands near the angle of the lower jaw, with 
a temperature of 40° C. (104° F.), and rapid extension to the proximal glands 
as far as the clavicle. Symptoms of pulmonary complication were not pres- 
ent. Eapid emaciation and marked anaemia supervened, followed after six 
weeks by swelling of axillary and inguinal glands. Ophthalmic examination 
revealed the same conditions of retina and papilla as in leukaemia or Bright's 
disease. A few days after the beginning of the disease profuse diarrhoea 
and reduction to nearly normal temperature occurred. The diagnosis was 
between malignant lymphoma and tubercular adenitis. During the further 
course of the disease bronchial breathing in both lungs appeared. Heart, 
liver, and spleen appeared to be normal. Urine normal, but increase of tem- 
perature and respirations took place during this time. Death occurred in 



rUBEROl LOSIS OF LYMPHATIC GLANDS. ; ' ::; ' 

Lees than five months. At the autopsy, the Lungs were found congested and 
oedematous, with rod hepatization of the lower lobes and a few miliary tuber- 
cles. The Bpleen contained many miliary tubercles the size of the head of a 
pin, ami most of them in a state of cheesy degeneration. The mesenteric 
glands were much enlarged, and a lew of them in a condition of cheesy de- 
feneration and calcification. In the cheesy matter bacilli were found. All 
the cervical glands were affected with softening and cheesy degeneration 
in the centre. The calcification of mesenteric glands pointed to an earlier 
affection. The disease remained latent and recurred in the same glands, and, 
later, extended to the cervical glands. This case resembles the cases de- 
scribed by Hilton-Fagge and Pye-Smith. 

In reference to the dissemination in cases of acute miliary tuberculosis, 
Weigert has pointed out that in some cases the bacilli are conveyed through 
the lymphatic system successively until they reach the general circulation, 
while in others, and by far the greater number, generalization of the tuber- 
cular process takes place 'more directly by the entrance of tubercular prod- 
ucts through a vein, — an occurrence which is followed at once by rapid and 
extensive diffusion by embolic processes; when the bacilli have reached the 
systemic circulation, the intensity of symptoms and subsequent course of 
the disease depend on the number of bacilli which the blood contains. As 
regards the frequency of secondary infection of the lungs in cases of gland- 
ular tuberculosis, Frankel found it present in only 18 out of 148 cases. In 
making a differential diagnosis it becomes necessary to distinguish tubercular 
adenitis from simple adenitis, suppurative adenitis, syphilitic adenitis, car- 
cinoma, lymphoma, lymphosarcoma, and pseudoleukemia. 

Simple adenitis is the result of the entrance into the lymphatic circula- 
of noxae that neither produce suppuration nor the formation of new tissue. 
A number of glands corresponding to the direction of the lymph-current 
from the infection-atrium, through which the irritant gained entrance, en- 
large, but the inflammatory swelling subsides shortly after the cessation of 
the primary cause, with perfect restoration of the structure and function of 
the affected glands. Suppurative adenitis is an acute affection which ter- 
minates in the formation of pus in a few days. Syphilitic adenitis devel- 
oping in the course of a primary syphilitic sore only attacks the glands con- 
taminated with lymph coming from the infected area. The adenitis which 
accompanies secondary and tertiary syphilis is not limited to a single region; 
nearly all of the external lymphatic glands are more or less enlarged, but 
especially those in the occipital and cubital regions. Carcinoma never occurs 
as a primary lesion in the lymphatic glands, and when regional infection has 
occurred it is not difficult to locate the primary tumor. Lymphoma is a be- 
nign tumor of the lymphatic glands, and as such is always met with as a 
single tumor. Lymphosarcoma represents the primary malignant tumor of 



536 PRINCIPLES OF SURGERY. 

the lymphatic glands, and gives rise to regional and general infection, the 
infection in these respects resembling the clinical tendencies of tubercular 
adenitis. Lymphosarcoma, however, is a tumor, not an inflammatory swell- 
ing, and, consequently, the tissues of which it is composed do not undergo 
degeneration and necrosis at such an early stage, and the rapid tissue-in- 
crease leads to the formation of large tumors, while tubercular glands the 
size of an almond contain cheesy material. The unlimited growth which 
characterizes sarcoma is checked in the tubercular glands by necrosis of the 
cells which compose the swelling. In pseudoleukemia the fixed tissue-cells 
of the parenchyma of the glands proliferate by being acted upon by a mi- 
crobe as yet unknown; but this microbe, unlike the bacillus of tuberculosis, 
is diffused more extensively through the lymphatic system, involving one 
region after another until, after the disease has been once well developed, 
almost every lymphatic gland in the body has become infected. The sup- 
posed microbe of pseudoleukemia possesses the property of producing new 
tissue by its action upon the fixed cells, but the new product does not un- 
dergo caseation. As the last and infallible diagnostic measures, must be 
mentioned the search for the bacillus of tuberculosis by the use of the micro- 
scope and inoculation experiments. 

Prognosis. — A tubercular lymphatic gland is always a source of 
danger. Even if the disease becomes latent, a recurrence may take place 
at any time, and lead to rapid regional and general infection, or general 
infection may take place directly from an old cheesy focus by the en- 
trance of bacilli or their spores into a vein. The prognosis is very grave 
if the patient is anaemic and the glands on both sides of the neck are 
affected at the same time. Frankel estimates the average duration of the 
disease from three to four years. In the cases which he collected the 
shortest time was two months and the longest thirty years. Sooner or 
later, pulmonary or diffuse general tuberculosis is almost sure to take 
place. A spontaneous cure is possible if secondary infection occur in cases 
where only a few of the glands have become infected, and suppuration 
results in the elimination of all the infected tissue. Suppuration only 
hastens a fatal termination if many glands are affected. 

Treatment. — As primary lymphatic tuberculosis, in most instances, 
signifies the entrance of bacilli through a loss of continuity of the skin 
or a mucous membrane, or through the socket of a carious tooth, locali- 
zation occurring in one of the nearest glands to the portio invasionis, it 
must be regarded primarily as a local process amenable to timely surgical 
treatment. The capsule of the lymphatic glands constitutes a very effi- 
cient barrier against infection of the paraglandular tissue for a long time, 
and perforation of the capsule can only take place after the disease has 
made considerable progress, and has been followed by extensive caseation 



TUBERCULOSIS OF LYMPHATIC GLANDS. 537 

and especially by suppuration. Early operative interference is as necessary 

in the treatment of tubercular adenitis as in the treatment of malignant 
tumors, and holds out more encouragement , so far as a permanent cure is con- 
cerned. By a thorough removal of the primary foci of infection, successive 
infection of proximal glands and general miliary tuberculosis are pre- 
vented almost to a certainty if the operation is performed before the 
disease has extended beyond the capsule of the glands. If the operation 
is done at such a favorable time it is not attended by any great difficulties, 
as the glands can be readily excised, and, as suppuration has not taken 
place, the wound usually heals by primary intention. If, however, the 
tubercular inflammation has involved many glands, and has extended to 
the connective tissue surrounding them, the operation becomes one of the 
most formidable in surgery, on account of the close proximity of impor- 
tant vessels that are often imbedded in the mass. Under such circum- 
stances complete removal is frequently impossible and early local recidiva- 
tion is inevitable, owing to imperfect removal of the primary microbic 
cause. Traumatic dissemination is very likely to follow all imperfect opera- 
tions in which portions of glands or infected capsules are left behind, as the 
operation wounds are inoculated with bacilli liberated during the operation. 
I have seen a number of such cases, as early as a week after the operation, 
the entire surface of the wound covered by a thick layer of granulation- 
tissue, which showed all the histological evidences and possessed all the 
bacteriological properties of tubercular tissue. As a testimony in favor of 
the operative treatment of tubercular adenitis, I will quote from the paper 
of Schuell, who collected 56 cases of tuberculosis of the cervical glands 
that were treated by extirpation in the clinic at Bonn. In 37 of these 
cases he was able to learn the ultimate result. In 57 per cent, the opera- 
tion was followed by complete recovery, in 27 per cent, the disease re- 
turned at the site of operation, and in 4 cases death resulted from pul- 
monary tuberculosis. The largest number of cases were patients between 
10 and 20 years of age. 

Frankel reports 128 cases operated upon by Billroth, some of the 
operations being quite serious; in 16 cases the internal jugular vein had 
to be tied. In 91 of the operations the wound healed by primary union, 
and in 25 the healing was retarded by suppuration. Erysipelas compli- 
cated the result five times. In one of these cases a large part of the tuber- 
cular mass was left, and it was noticed that the erysipelas had no effect 
on the tubercular process. Only in 49 of the cases operated on could the 
final result be obtained. Taking three and a half years as the time when 
the patient could be considered exempt from a recurrence of the disease, 
it was ascertained that in 24 per cent, no relapse followed the operation, 
a local relapse was observed in 14 per cent., and reappearance of the dis- 

34a 



538 PRINCIPLES OF SURGERY. 

ease distant from the seat of operation in 4 per cent. The results of 
operation for tuberculosis of the lymphatic glands have shown the neces- 
sity of early operating, as delay renders the operation more difficult, on 
account of the progressive regional dissemination of the disease and the 
occurrence of pathological changes within and around the affected glands, 
which render their complete removal more difficult; while at the same 
time the danger of general infection increases with the local extension of 
the disease. If the glands have suppurated, or if the capsule has become 
perforated and tubercular periadenitis or suppurative periadenitis has 
taken place, and many glands are simultaneously affected, it may not be 
advisable to resort to excision, as when extensive connective-tissue infil- 
tration is present it would be almost impossible to remove all of the in- 
fected tissues. 

In such cases free incisions should be made, and the tubercular 
product be removed with a Volkmann spoon. The proximal glands which 
have not undergone such extensive secondary pathological changes can be 
excised. The scraped surface is freely iodoformized and the wounds are 
sutured and drained. In removing the glands of the neck it is always im- 
portant to expose the infected area by a large incision. The operator 
should not only feel, out see, every gland he removes. Accidents are more 
liable to happen by removing the glands through a small than a large in- 
cision. As in cases of secondary carcinoma of the lymphatic glands the 
extent of the disease is only ascertained after incision, so in glandular 
tuberculosis the extent of the area of infection can only be determined 
after the external incision is made. Whole chains of small glands which 
could not be felt through the skin are then exposed. In tuberculosis of 
the glands of the neck the region between the mastoid process and the 
angle of the lower jaw is almost always the primary seat of infection. 
From here either the chain of glands behind the sterno-cleido-mastoid 
muscle or the deep glands which follow the sheath of the large vessels of 
the neck are affected, or the superficial and deep lymphatics are affected 
simultaneously. It has been my custom to expose the glands occupying 
the upper region of the neck by a transverse incision, extending from the 
tip of the mastoid process of the temporal bone to the lower angle of the 
jaw, and from there along the lower border of the bone, as far as the dis- 
ease extends in the submaxillary region. This incision is joined by an- 
other, extending from the angle of the lower jaw either along the anterior 
border of the sterno-cleido-mastoid muscle as far as its sternal insertion, 
if the deep glands are to be removed, or, if the posterior superficial set of 
glands are affected, it is carried in a downward and backward direction, 
following the chain of enlarged glands. If the latter incision is selected, 
the external jugular vein is divided between two ligatures. The platysma 



TUBERCULOSIS OF LYMPHATIC GLANDS. 539 

myoides muscle is divided throughout the whole length of the incision 
re an attempt is made to remove any of the glands. The surgeon 
should aim to remove, as nearly as he can, all of the injected glands in one 
continuous siring. In many cases one or two tubercular glands will be 
found imbedded in the lower portion of the parotid gland, and very fre- 
quently also in the submaxillary salivary gland. If the tubercular glands, 
with their capsules, can be enucleated, this should be done; but if this 
is impossible, it is better to remove the lower portion of the parotid with 
them in preference to leaving any infected tissue behind. Under the same 
circumstances I prefer to extirpate the submaxillary gland in toto. If the 
deep glands of the neck must be removed, it is absolutely necessary to 
divide the sterno-cleido-mastoid muscle near its centre, and then reflect 
both ends nearly as far as the origin and insertion of the muscle, which 
freely exposes not only the affected glands, but also the important struct- 
ures of the neck, which it is important to avoid in the dissection. The 
dissection must always be made with the greatest care, and in the vicinity 
of the large vessels every structure must be identified before it is sepa- 
rated. The finger and blunt-pointed, curved scissors are the most impor- 
tant instruments in making the deep dissection. The internal jugular 
vein should be exposed before any of the deep glands are removed, for if this 
structure is seen it can be carefully followed the whole length of the neck 
without wounding it unintentionally. If the internal jugular vein is im- 
bedded among the enlarged glands, and cannot be isolated without great 
danger of injuring it, it is better to resect it between two ligatures than to 
run the risk of wounding it accidentally. The chain of enlarged glands is 
followed as far as possible, as it is much better to remove a few healthy 
lymphatic glands than to leave minute, almost invisible foci of the dis- 
ease. After all the infected glands have been removed the continuity of 
the divided muscle is restored by suturing. At least six catgut sutures 
are necessary to join the ends accurately. I have usually succeeded in 
removing all the glands after division of this muscle without dividing the 
spinal accessory nerve, but, should this be necessary, the divided ends 
are joined by suturing before the muscle is united. Drainage in the sub- 
maxillary region and at the most dependent point of the wound in the 
neck must always be established. The platysma muscle should be united 
with buried sutures before the skin is sutured. I have recently, except 
in cases of very limited tuberculosis of the cervical glands, abandoned 
the straight incision, which is followed so often by a disfiguring scar, and 
have substituted for it an incision which resembles the shape of the letter 
S, as here illustrated. This incision affords free access to the deep tissues 
of the neck and the entire chain or chains of tubercular glands, and the 
resulting sear never appears in the form of an elevated, disfiguring ridge. 



540 PKINCIPLES OF SURGERY. 

Wounds of the neck, on account of the irregular outlines of the neck, 
shoulder, and chest, require a very copious antiseptic dressing to effectually 
exclude the entrance of pathogenic microorganisms after the operation. 
The dressing should be kept in place by a few turns of the plaster-of-Paris 
bandage, which also keeps the head in proper position during the time 
required in the healing of the large wound. The sutured muscle must be 
kept in a relaxed position until firm union has taken place between the 
sutured ends, which usually requires from two to three weeks. On the 
second or third day the dressing is changed, the drains are removed, and, 
if the wound has remained aseptic, the second dressing can be allowed to 
remain for ten days or two weeks, when it is changed, and the superficial 
stitches are removed. If all of the diseased tissues have been removed, 
and the wound has remained aseptic, the healing process will be found 
nearly completed at this time. 




Fig. 182. — S-shaped Incision in the Operation for the Removal of Tubercular 
Glands of the Neck. 

Local recurrence of the disease should only stimulate the surgeon 
to continue the active warfare, and glands are removed as soon as they 
can be felt. I have repeatedly performed, on the same patients, three and 
four operations in as many years, and had the satisfaction of finally eradi- 
cating the disease completely. In one case I performed 21 operations during 
the course of five years with ultimate complete success. Parenchymatous in- 
jections of carbolic acid, so strongly recommended by Hueter in the treat- 
ment of tubercular glands, have little or no effect in either arresting further 
development of the disease in the affected glands or in preventing further 
regional infection. I have seen, in cases treated by this method, glands 
finally destroyed by suppuration caused by the punctures; but the bacilli 
remained in the cicatricial tissue, as was evident by the cedematous, congested 
scar, and from here additional glands became infected. 



TUBERCULOSIS OF PERITONEI M. 5 I 1 

Genzmer advised ignipuncture in fche treatmenl of 1 ube re alar glands, 
and claims for this method excellent results. This treatment is applicable 
only in cases where a few of the more superficial glands are affected, and 
where patients positively refuse to submit to a more radical procedure. 
It is absolutely contraindicated when many glands are affected, as in cases 
where the glands are affected they have undergone extensive secondary 
pathological changes. The general treatment of tuberculosis of the 
lymphatic glands is the same as in the other forms of local tuberculosis. 
I have seen the best effects from the administration of guaiacol, arsenic, 
and iron, followed or alternated by codliver-oil. All external applications 
to bring about resolution are worse than useless. 

TUBERCULOSIS OF PERITONEUM. 

Tubercular peritonitis occurs as one of the lesions of acute general 
tuberculosis, with chronic pulmonary phthisis, with tubercular inflamma- 
tion of the genito-urinary tract, and as a local inflammation. As a sur- 
gical lesion only the local form will be considered here. 

Bacteriological Remarks. — The susceptibility of the peritoneum to 
tubercular infection has been w-ell established by numerous inoculation 
experiments. The peritoneum can, under favorable conditions, dispose 
of a large dose of a pure culture of pus-microbes, but the implantation 
of a minute fragment of tubercular tissue in animals susceptible to tuber- 
culosis is almost certain to be followed by genuine local and general tuber- 
culosis. For the surgeon, only those forms of peritoneal tuberculosis have 
interest which are either caused by an extension of an adjacent tubercular 
process to the peritoneum or from primary localization of the bacillus 
within or upon this membrane. The prevalence of the affection in the 
female sex, among the cases which have been reported, points to the 
Fallopian tubes as a frequent primary seat of infection, with secondary 
invasion of the peritoneum from this source. Although the genital organs 
in the male are more frequently the seat of tuberculosis than in the 
female, so far only a few cases of peritoneal tuberculosis in males have 
been reported: by Kummell, Lindfors, and others. Recent clinical and 
post-mortem observations have shown that in not an inconsiderable num- 
ber of cases peritoneal tuberculosis is secondary to intestinal tuberculosis. 
The peritoneal complication may set in during the active stage of in- 
testinal tuberculosis or long after the intestinal lesions have healed. 
Tuberculosis of the peritoneum, by extension from a tubercular focus in 
the genital organ, can only mean an infection by contact: the bacillus of 
tuberculosis transferred from the primary seat of infection, and localiza- 
tion by implantation upon the peritoneal surface. Implantation experi- 
ments in animals furnish a good illustration of the manner in which the 



542 PRINCIPLES OF SURGERY. 

process becomes diffuse. At the point of implantation a granulation-mass 
forms around the graft, and from here innumerable tubercle-nodules take 
their starting-point, forming everywhere new centres of infection. The 
movements of the abdominal walls during respiration and the peristaltic 
action of the intestines are potent factors concerned in the local dissemi- 
nation of the tubercular infection. Anatomically, the peritoneum is so 
closely allied to the lymphatic glands that we have every reason to believe 
that primary tuberculosis can occur in this structure as well as in the 
lymphatic glands. In primary tuberculosis of the peritoneum infection 
takes place in the same manner as in intact joints, by floating bacilli be- 
coming arrested in the capillary vessels of the membrane, where the 
primary nodule forms, from which, again, as from a graft, local dissemi- 
nation takes place. These cases are, in the true sense of the word, not 
cases of primary tuberculosis, as the peritoneal affection is only a local 
expression of an antecedent infection. As the peritoneum is endowed 
with absorptive capacities of a high degree and is in direct communication 
with the lymphatic system, we would naturally expect that tuberculosis 
of this structure would lead to early general dissemination. But in peri- 
toneal tuberculosis we observe the same tendency to limitation of the in- 
fective process as in joints, by the formation of an impenetrable wall of 
connective tissue, which imparts so often to this form of peritonitis its 
circumscribed character. 

Clinical Studies. — Kummell looks upon peritoneal tuberculosis as a 
purely local affection, amenable to surgical treatment in the same sense 
and to the same extent as tuberculosis of a joint. That some of these cases 
can be permanently cured by local treatment is well show T n by a case treated 
by Sir Spencer Wells twenty-six years ago by abdominal section, the pa- 
tient having remained, up to the time the report was made, in perfect 
health. In a paper on this subject Fehling reports 4 cases of his own, 
and gives an account of all the operations which had been done up to 
that time: 21 in number. Of this number, 15 recovered, and the patients 
are known to have been well from one year to twenty-three years, and 
in a number of cases their condition was learned four to five years after 
the operation. Six of the patients died: 2 of sepsis, 1 of pyasmia several 
months after the operation, and 3 from the continuance of the disease for 
which the operation was performed. In 5 of the cases ascites attended 
the tuberculosis; in 3 the swelling was not due to effusion, but to ad- 
hesions between intestinal loops that were covered with miliary tubercles. 

Of 54 cases of laparotomy for peritoneal tuberculosis, collected by 
Trzebicky, 4 died from the immediate consequences of the operation, 
while in a fifth death occurred after the operation from acute miliary 
tuberculosis, though the fluid had not reaccumulated. One case died in 



TUBERCULOSIS OF PERITONEUM. 543 

four months from general tuberculosis without the peritonitis disappear- 
ing: cures resulted in 40 cases, though here and there evidence of pul- 
monary tuberculosis was reported. The majority of cases were females, 
which may find its explanation in the fact that most were operated upon 
under error in the diagnosis of ovarian cyst. One of the more recent 
and comprehensive works on tuberculosis of the peritoneum, which has 
appeared from the pen of Yierordt ("Ueber die Tuberculose der serosen 
Haute," in Zeitschrift f. hlin. Medicin, Bd. xiii, Heft 2), should be con- 
sulted by those who wish to secure for reference an exhaustive treatise 
on this subject. The statistics are yet too meagre, the correctness of diag- 
nosis not entirely above doubt, and the period of observation after opera- 
tion not long enough; but, in view of the results, there is no longer any 










Fig. 183. — Tubercular Peritonitis (Parietal Peritoneum). The inflammatory process 
is accompanied by marked connective-tissue hyperplasia. A, connective-tissue hyper- 
plasia; B, blood-vessels; C, caseated area; D, giant cell; E, small round-cell infiltra- 
tion. (Eosin and haematoxylin stain.) 

justification for expectant treatment. Even though in some cases re- 
covery was not permanent, the fluid did not reaccumulate, and the pa- 
tients were relieved of their distress. Spontaneous recovery from tuber- 
cular peritonitis is exceptional, and operative interference is indicated 
the more, as it would seem that, in many cases, tuberculosis of the peri- 
toneum is a primary affection and the source of general infection. As all 
other therapeutic measures are of no permanent value in such cases, and 
laparotomy done under aseptic precautions may be considered almost free 
from danger, the operation is certainly strongly indicated. 

Pathology and Morbid Anatomy. — The effect of the bacillus of tuber- 
culosis on the peritoneum is not uniform, and the conditions found in 
peritoneal tuberculosis are variable. Lindfors, in a clinical and patho- 



544 PRINCIPLES OF SURGERY. 

logical study, based on 109 recorded cases of peritoneal tuberculosis, 
divides the cases into seven classes. He states that the acute variety may 
assume the form of circumscribed, general, or suppurative peritonitis; 
in the chronic form there may be a free or encysted effusion, there may 
be simple adhesions, or the intestines may be so adherent as to cause intes- 
tinal obstruction. Hyperplasia of the connective tissue is one of the con- 
spicuous pathological features of peritoneal tuberculosis. Two distinct 
pathological forms are met with clinically: fibrinoplastic and hydropic. The 
former variety is characterized by copious fibrinous exudates, diffuse, firm 
adhesions; the latter by diffuse miliary tubercles and localized or .diffuse 
ascites. Lindf ors thinks that the presence of acute or chronic pleurisy has an 
important bearing on the diagnosis of tubercular peritonitis. He is strongly 
in favor of laparotomy and the free use of iodoform within the peritoneal 
cavity. The conditions found in local tubercular peritonitis, in cases sub- 
jected to operative treatment and in examinations made in the post- 
mortem rooms, are such that all cases of this kind can be conveniently 
classified in three principal groups upon a pathological basis: — 

1. Tubercular Ascites. — The peritoneum is thickened, hyperagmic, and 
studded with masses of tubercle-tissue in the form of miliary nodules. 
The omentum is usually similarly affected. If the effusion is general, 
occupying the whole peritoneal' cavity, the adhesions are few and slight. 
If the fluid is encapsulated, the walls of the cavity are formed by intestinal 
loops, which are adherent among themselves and to the surrounding 
structures. The circumscribed form usually takes its origin from the 
floor of the pelvis, and often gives rise to a swelling which simulates an 
ovarian cyst to perfection. The fluid contained in the peritoneal cavity 
in the diffuse form, and in the confined space in the circumscribed variety, 
is either a clear, transparent serum, or serum in which small nocculi are 
suspended, or it has become slightly turbid from the admixture of the 
products of retrograde tissue-metamorphosis. The visceral peritoneum of 
the organs exposed to infection is in the same condition as the parietal peri- 
toneum. Coagulation-necrosis and caseation of the nodules appear to be 
retarded for a much longer time than in cases of glandular tuberculosis. The 
amount of fluid may vary from a teacupful in the circumscribed to 4 or 6 
gallons in diffuse tubercular ascites. Secondary infection is found most fre- 
quently in the spleen, pleurae, and lymphatic glands. 

2. Fibrinoplastic Peritonitis. — In this form of tubercular peritonitis 
no fluid is found in the peritoneal cavity. The bacillus of tuberculosis 
produces a copious inflammatory product, and the peritoneal surfaces, 
which are studded with miliary tubercles, are covered by a thick layer 
of gelatinous fibrin, which cements together all the adjacent serous sur- 
faces, so that the whole abdominal cavity appears to be filled with a large, 



TUBKIUM LOSIS OF PERITONEUM. 545 

mass, composed of all the viscera adherent to each other, and with 
the interspaces between them Tilled with fibrin. The inflammatory product 
in these cases is rich in fibrin-producing substances, while the liquid 
transudation is either scanty or is absorbed as soon as it is poured out. 

3. Adhesive Peritonitis. — In this variety of tubercular peritonitis the 
bacillus of tuberculosis exerts its pathogenic properties more on the fixed 
tissue-cells than the blood-vessels. The primary inflammatory exudation 
is slight, but the endothelial cells proliferate new tissue, which undergoes 
cicatrization, giving rise to firm and extensive adhesions. The plastic 
peritonitis may be so extensive as to cause intestinal obstruction from 
perfect immobilization of a large portion of the intestinal tract. In this, 
as well as in the foregoing form of tubercular peritonitis, ulceration of 
the intestine may take place, resulting in the formation of a bimucous, 
internal fistula if the openings in two adjacent loops correspond, or the 
formation of a faecal abscess with a subsequent faecal fistula. 

Symptoms and Diagnosis. — As tubercular peritonitis without effusion 
is not amenable to successful surgical treatment by laparotomy, nothing 
will be mentioned in reference to the diagnosis and treatment of the 
fibrinoplastic and adhesive varieties. Tubercular ascites is a chronic affec- 
tion, especially when it occurs in the circumscribed form. Pain and ten- 
derness are not prominent or even constant symptoms. The general 
health is at first but little impaired. Fever is slight or entirely absent. 
If the effusion is general, it comes on slowly, almost insidiously, as in 
ascites from other causes. From the absence of adhesions the fluid 
changes its location according to the position of the patient. If the pa- 
tient is placed in the dorsal, recumbent position, the lumbar regions are 
dull on percussion; if placed on the side the upper lumbar region is tym- 
panitic, while the area of dullness on the opposite side is increased. In 
circumscribed tubercular peritonitis with encapsulation of the fluid, the 
swelling appears first either in the hypogastric or one of the iliac regions. 
The area of dullness does not change by placing the patient in different 
positions. In free ascites tuberculosis of the peritoneum should be sus- 
pected, if the ordinary causes of ascites, cirrhosis of the liver, valvular 
disease of the heart, and the presence of an intraabdominal malignant 
tumor can be excluded. Circumscribed tubercular ascites might be mis- 
taken for ovarian cyst, pregnancy, pyosalpinx or hydrosalpinx, pyonephro- 
sis or hydronephrosis, cyst of pancreas, enlarged gall-bladder, and pelvic 
abscess. Fluctuation is a symptom common to all of these conditions, and 
a differential diagnosis can only be made by a careful study of the clinical 
history and by a thorough examination. Pregnancy can usually be ex- 
cluded by ascertaining the size of the uterus and by the presence or ab- 
sence of the usual signs of gestation. A pyosalpinx or hydrosalpinx can 



546 PRINCIPLES OF SURGERY. 

generally be recognized by bimanual exploration, especially if the exami- 
nation is made, as it should be, under the influence of an anaesthetic. A 
pelvic abscess is always preceded by an acute suppurative parametritis or 
perimetritis, attended by severe symptoms which are absent in tubercular 
peritonitis. Cystic affections of the gall-bladder, pancreas, and kidney 
begin in the upper part of the abdominal cavity, while the reverse is 
usually the case in tubercular ascites. 

The greatest difficulty presents itself in differentiating between a 
circumscribed tubercular ascites and an ovarian cyst. So close is the clin- 
ical resemblance of these two affections that a positive diagnosis is almost 
impossible without the aid of an exploratory laparotomy, and, as both 
affections can only be treated successfully by abdominal section, it is suffi- 
cient for all practical purposes to narrow the diagnosis down to one of 
these and reserve a positive diagnosis until the abdomen is opened. 

Treatment. — The surgical treatment of tubercular peritonitis with 
effusion by laparotomy has yielded sufficiently satisfactory results to 
make it an established procedure in such cases in the future. A sponta- 
neous cure is the exception; death from local extension of the disease and 
from general infection the rule. A case came under my observation a 
few years ago where I have every reason to believe that tubercular ascites 
disappeared spontaneously. The patient was a woman, 40 years of age, 
with a marked hereditary tendency to tuberculosis, several sisters having 
died of pulmonary tuberculosis. She was the mother of several children, 
the youngest being 6 years old. She was brought to me by her family 
physician with the diagnosis of ovarian cyst. She had been ailing for two 
vears. TThen I examined her the swelling was as lar^e as a child's head, 
occupying the hypogastric and left iliac region. Fluctuation distinct; no 
pain and but little tenderness on pressure; menstruation regular. Gen- 
eral health only slightly impaired. After a careful examination I coin- 
cided with the diagnosis, and advised an early operation. Soon after this 
time the swelling began to diminish in size and disappeared completely in 
the course of a year, but the general health, instead of improving, began 
to fail. After the disappearance of the swelling she began to suffer from 
a deep-seated pain at a point corresponding to the cartilage of the eighth 
rib on the left side, and in the course of a few months a fluctuating swell- 
ing appeared under the costal arch at that point. Tuberculosis of the ribs 
was suspected, but at the time of operation an encapsulated tubercular 
abscess was found in the abdominal cavity, to the left of the great curva- 
ture of the stomach and above the splenic flexure of the colon. A large 
quantity of liquefied, caseous material was evacuated. The wall of the 
abscess was lined with a thick layer of granulation-tissue, which was 
thoroughly removed with a sharp spoon, and after irrigation the cavity 



TUBERCULOSIS OF PERITONEI - M. 547 

was carefully dried and packed with iodoform gauze. The wound healed 
by primary intention, and the entire cavity closed in the course of four 
weeks without a drop of pus. The woman has since greatly improved in 
health and is completely relieved of her pain. There can hardly be a 
question that the accumulation of fluid which was mistaken for an ovarian 
cysl was a limited ascites, caused by a circumscribed tubercular peritonitis, 
and that the infection in the upper portion of the abdominal cavity re- 
sulted from this, the primary depot. It is not at all improbable that, had 
an operation been performed at the time it was advised, this extension of 
the infection might have been prevented. 

The results obtainable by laparotomy in the two different forms of 
tubercular ascites are well shown by tw T o cases which occurred in my own 
practice. The first patient was a girl, 17 years old, without a tubercular 
history. She had always been in good health until about a year before she 
came under my observation, when she commenced to suffer from pain in 
the left iliac region, and soon after a perceptible swelling appeared in 
that locality, which gradually increased in size until the time I saw her, 
when it reached above the umbilicus and beyond the median line. Has 
never menstruated. Patient was anaemic and somewhat emaciated, but 
was never confined to bed. Examination revealed no disease in any of the 
important organs. Diagnosis of ovarian cyst had been made by several 
physicians. The abdomen was opened by a median incision, and a large 
quantity of clear, straw-colored serum escaped as soon as the peritoneum 
was incised. The parietal peritoneum, as well as the intestines, which 
formed a part of the wall of the cavity, w T ere studded with innumerable 
nodules the size of a millet-seed. These nodules were largest and most 
numerous in the region of the left Fallopian tube, which, however, was 
normal in size. The cavity was dried and freely dusted with iodoform, and 
a Keith glass drain inserted as far as the floor of the space of Douglas. 
A large quantity of serum was removed from the tube for the first few 
days, when it became more and more scanty, so that the glass tube could 
be removed at the end of the second week. Through a small, fistulous 
tract serum continued to escape for six weeks, when the fistula closed. 
The patient gained fifteen pounds in weight, and a year after the operation 
was in perfect health, w T ith no signs of a local return. That the peritonitis 
in this case was tubercular was demonstrated by an inoculation experi- 
ment. A nodule was removed from the peritoneum and implanted into 
the peritoneal cavity of a guinea-pig, with a positive result. The second 
case was a woman, 42 years of age, without any history of tuberculosis in 
her family. She is the mother of a large family, the youngest child being 
5 years of age. Her abdomen began to enlarge four months before she 
came under my care. Pain not severe, but gradual loss of flesh and 



548 PRINCIPLES OF SURGERY. 

strength. As no local cause for the ascites could be found, the abdomen 
was opened in the median line and at least two pailfuls of clear serum 
escaped. The intestines and parietal peritoneum presented an exceed- 
ingly vascular apparance and were studded with minute miliary nodules. 
These nodules, again, were largest in the pelvis, but both tubes were found 
in a normal condition. The same course was pursued as in the first case, 
and drainage was kept up for two weeks, when the flow of serum was so 
scanty that it was deemed advisable to remove the tube. The wound 
healed completely in a few days, and the patient left the hospital greatly 
relieved. The fluid, however, accumulated so rapidly that in two weeks 
she had to be tapped, and from this time on the patient could not leave 
her bed. The tapping had to be repeated every two weeks. Symptoms of 
pulmonary phthisis developed soon after she left the hospital, and death 
from general miliary tuberculosis occurred in less than three months after 
the operation. 

The clanger of reaccumulation of fluid and general infection is much 
greater in diffuse tubercular peritonitis than in the circumscribed form, 
as in the latter the area of infection is more limited, and general infection is 
less likely to occur on account of the presence of a wall of plastic material 
which surrounds the tubercular field. In operating for circumscribed 
tubercular ascites it is very important to exercise great care in opening 
the abdominal cavity, as a loop of adherent intestine may be found at the 
point where the incision is made. The peritoneum must be recognized and 
carefully divided in order to prevent wounding of the bowel, should such 
a condition be met with. Iodoformization of the cavity is one of the 
important indications of treatment. Drainage must be maintained until 
accumulation of serum in the tube has ceased. Uniform equable com- 
pression of the abdomen with strips of adhesive plaster or a well-fitting 
bandage should be kept up throughout the entire after-treatment. In 
cases where a well-defined local tubercular focus is found, which we have 
reason to regard as the cause of the peritonitis, this should be removed or 
rendered harmless by appropriate treatment. A tubercular Fallopian tube 
should be removed if this can be done. Other caseous foci are removed 
with a sharp spoon, or they can be destroyed or rendered harmless by 
ignipuncture and thorough iodoformization. 

Lauenstein attributes the curative effect of laparotomy in cases of 
tubercular ascites to the admission of atmospheric air, and, acting upon 
this theory, inflation of the abdominal cavity after tapping has been re- 
sorted to as a therapeutic agent, but the results following this treatment 
have not been encouraging. March tthurn reports 19 cases of tuberculosis 
of the peritoneum treated by laparotomy and adds to these 17 additional 
cases from a former report. Twenty-one were permanently cured. In the 



TUBERCULOSIS OF PBBITONE1 M . 549 

remaining cases in which tuberculosis existed in other organs the results 
consisted only in temporary improvement. The diagnosis in all cases was 
confirmed by microscopical examinations. Roesch collected 358 cases sub- 
jected to operative treatment, 20 died from the effects of the operation, 
51 died from tuberculosis in other organs, and 250, or 70 per cent., were 
cured. In 2 cases of limited tubercular ascites the writer has secured ex- 
cellent results from tapping followed by injection of 4 drachms of a 10- 
per-cent. emulsion of iodoform in glycerin. Both cases resulted, ap- 
parently, in a permanent cure. Both patients were placed at the same 
time upon the internal use of guaiacol. I have since treated 2 additional 
cases in the same manner with similar results, and therefore feel confi- 
dent that this treatment is entitled to a more extended trial. 



CHAPTER XXII. 

TUBEECULOSIS OF BONES AND JOINTS. 
TUBEKCULOSIS OF BONE. 

Next to the lungs and lymphatic glands, the bones are most fre- 
quently the seat of tubercular infection. Tuberculosis of the bones is 
an exceedingly frequent affection in children and young adults. Its 
favorite location is in the epiphyseal extremities of the long bones, al- 
though it is quite frequently met with in the short bones of the carpus 
and tarsus and some of the flat and irregular bones, as the ribs, scapula, 
ileum, and vertebra?. 

Embolic Infection the Cause of Osseous Tuberculosis. — Practically, 
direct tubercular infection does not occur, and when the disease has made 
its appearance it is only an evidence of the existence of a tubercular focus 
in some other organ. We observe clinically, what Mueller has demon- 
strated experimentally, that, when the bacilli of tuberculosis are present 
in the blood-current, very often localization takes place near the epiph- 
yseal cartilage in young persons by the microbes becoming arrested in 
one of the terminal branches of an artery, the lumen of which becomes 
obliterated by the presence of a minute embolus of granulation-tissue con- 
taining bacilli; or the lumen of the vessel is gradually diminished by the 
formation of a mural thrombus, which forms around bacilli implanted 
upon the vessel-wall, and the vessel is finally completely obstructed by the 
growth of the thrombus. 

The new vessels in the vicinity of the centres of growth in the bones 
of young persons, on account of their imperfect structure and irregular 
contour, furnish the most favorable conditions for the arrest of floating 
granular matter and the localization of pathogenic microbes. The pre- 
disposing anatomical element goes far to explain the frequency with which 
we meet with tubercular foci in the epiphyseal extremities of the long 
bones. 

The following table, prepared by Schmallfuss, gives a good idea of 
the relative frequency with which different bones are affected with tuber- 
cular lesions: — 

(550) 




Fig. 184.— Tuberculosis of the Lower Epiphysis of the Humerus. 



TUBERCULOSIS OF BONE. 






BILI.KOTH. 


Jakfe. 


1 Per 


- 


Pi i: 1 KNT. 


ra. 


Vertebra. 


! 


Ki 






Foot . 


21 




19 


Cranium ami Face. 


Hip. 


13 


Hip. 


16 


Hip. 


Knee. 


10 




9 


Sternum and ribs. 


Hand. 




Hand. 


8 




Elbow. 


4 


Vertebra. 




: 


Pelvis. 




Tibia. 


4 


Pelvis. 


Cranium. 


3 


Cranium. 


4 


Tibia. Fibula, and 


9 ::um. Clavicle, 




Pelvis. 


3.6 


Ft-mur. 


and Ribs. 


3 


Sternum, etc. 


3.6 


Shoulder. 


Shoulder. 




Femur. 


1.9 




Femur. 


1 


Shoulder. 


1.5 


Humerus. 


Tibia. 


1 


Ulna. 


1.4 


Ulna. 


Fibula. 




Humerus. 


J 


Radius. 


Humerus. 




Radius. 


0.7 


Scapula. 


Scapula. 


0.6 


Fibula. 


0.5 




Ulna. 


0.6 


Patella. 


0.1 



It is safe to state that before puberty the primary lesion in tuber- 
cular affections of joints is located in one or both of the epiphyses of 
the bones which enter into the formation of a joint, while in the adult 
primary tuberculosis of the synovial membrane is of more frequent oc- 
currence. As age advances and the process of ossification is completed, 
the predisposing localizing causes in bone apparently disappear, while the 
synovial membrane becomes more susceptible to primary localization. Of 
20-i specimens of tubercular joints obtained from patients of all ages, 
examined by Mueller. 156 were primary osteal and 46 primary synovial 
tuberculosis. 

Artificial Tuberculosis of Bone Produced by Direct Intravascular In- 
fection. — "William Mueller, formerly one of Konig's assistants, produced 
the characteristic clinical form of tuberculosis in bone experimentally 
by injecting tubercular material into the nutrient artery of long bones. 
Konig for a long time had claimed that the wedge-shaped sequestrum, so 
constantly found in tubercular foci in the articular extremities of the 
long bones, was due to occlusion of a small artery by a tubercular embolus. 
Muellers experiments were undertaken to produce this condition arti- 
ficially. He made 16 experiments on rabbits, injecting tubercular pus into 
the femoral artery, some in a peripheral, some in a central direction, with- 
out any positive results following. In a second series the same material 
was thrown directly into the nutrient arteries of the femur and tibia. Of 
10 of these cases, 2 showed a tubercular focus in the medulla of the diaph- 
ysis of the tibia; in another case miliary tuberculosis in the femur and 
tibia, and in the latter bone a small caseous nodule in the spongy part 
which contained numerous bacilli. The animals were killed eight weeks 
after injection, and showed no evidences of organic disease except a 
few tubercles in the lungs. Twenty experiments were made on young 



552 PRINCIPLES OF SURGERY. 

goats, 5 on sheep, and 2 on dogs. The tubercular material was injected 
directly into the nutrient artery of the tibia, the tibial artery being tied 
above and below the junction with this vessel. Primary union of the 
wound was obtained in all cases except in 1 dog. In the dogs and sheep 
all experiments resulted negatively. In the goats bone affections were 
produced that were identical with tubercular bone-lesions found in man. 
Most frequently the disease was established in the diaphysis, cheesy 
masses and granulation-tissue showing themselves in the medulla and 
cortical portion of the bone, or tubercular osteomyelitis with or without 
sequestration. Typical lesions were also found in the ends of the bones, 
with and without implication of the adjacent joints. In 2 of these cases 
the epiphysis was affected, while in 3 the shaft was involved. The follow- 
ing experiment made by him furnishes a good illustration of the identity 
of the bone disease produced experimentally with the disease as it occurs 
in man. 

Tubercular material was injected into the tibial artery of a goat 3 
months old. TTound healed in eight days. Some lameness four months 
later, gradually increasing during the next nine months. At the same 
time a swelling appeared at the knee-joint. Tibia painful on outer side. 
Animal killed thirteen months after the injection. At the necropsy there 
was found a typical fungous disease in the knee-joint, most advanced at 
the lateral aspects of the joint; a wedge-shaped sequestrum in one of the 
tuberosities of the tibia, a small granulation-mass in the centre of the head 
of the tibia, and two similar granulation-masses in the lower epiphysis of 
the femur. Excepting the lymphatic glands of the knee-joint, no other 
organs were affected. In some of the cases, pulmonary tuberculosis, twice 
general miliary tuberculosis. The remainder of the animals were killed 
when they began to show lameness: fourteen days to thirteen months 
after infection. The tubercular lesions thus produced were examined for 
bacilli, and these were never found absent. The starting-point, in every 
instance, must have been a tubercular embolus in one of the ultimate 
minute branches of the nutrient artery near the epiphyseal extremity of 
the bone. 

Clinical and Bacteriological Researches. — Schuchardt and Krause ex- 
amined a great variety of tubercular lesions, and came to the conclusion 
that tubercle bacilli can be found in them without exception, but, as a 
rule, few in number, and often only to be detected after long and patient 
search. They found them invariably present in cases of secondary and 
primary tuberculosis of synovial membranes, tuberculosis of bone, in tuber- 
cular abscesses, and in the latter cases not in the fluid contents, but in 
the granulations lining the abscess-wall. Eenken found the bacillus of 
tuberculosis in all cases of spina ventosa which he examined. Mueller 



TUBER( I LOSIS OF BONK. 553 

care fully studied numerous specimens of synovial and bone tuberculosis, 
with special reference to the existence of the bacillus of tuberculosis, and, 
although the results in a number of cases were negative, he believes that 
the most intimate and direct etiological relations exist between the bacil- 
lus and all tubercular lesions in bones and joints. Among others who have 
shown the never-failing presence of the bacillus in different forms of 
surgical tuberculosis, including bones and joints, may be mentioned 
Kanzler, Mogling, Bouilly, and Letulle. Tuberculosis of bone and fungous 
disease of joints, like lymphatic tuberculosis, have been, and by some are 
still, regarded as scrofulous affections. Kanzler wished to make a dis- 
tinction between scrofula aud tuberculosis, as he found the bacilli not as 
constant in the former, and observed that, after implantation of tissue 
of what he regarded as scrofulous affections of animals, the process was 
slower than after inoculation with the products of recognized forms of 
tuberculosis. Letulle considers scrofula and tuberculosis as belonging to 
one and the same disease, of which the former constitutes the milder form, 
and appearing externally, while the latter represents the graver form, 
attacking by preference the internal organs. The points made by the 
last two authors are too unimportant for further consideration as a scien- 
tific, or even practical, distinction between scrofula and tuberculosis as 
applied to affections of the bones or any other organs. The surgeon must 
recognize every lesion as tubercular in its origin, nature, and course in which 
the bacillus of tuberculosis can be found, from which successful cultivations 
can be made, and with which the disease can be artificially produced in ani- 
mals by inoculation. The presence of the bacillus of tuberculosis in the 
body and its localization in the medullary tissue of bone is the conditio 
sine qua non in the causation of osseous tuberculosis. The influence of 
traumatism in the etiology of tuberculosis of the bones and joints has 
been greatly overestimated. Traumatism as an etiological factor occupies 
a subordinate role, inasmuch as it can only be an exciting cause in persons al- 
ready infected with the essential cause. Max Schuller proved experimentally 
in animals infected with tuberculosis (for instance, through the respiratory 
tract) that a slight traumatism to a joint would determine localization of the 
microbes floating in the blood-current in the part injured, and that a tuber- 
cular synovitis or pararthritis would follow. 

On the other hand, Lannelongue and Ac-hard, in an experimental in- 
vestigation regarding the influence of trauma in the production of tuber- 
culosis, infected guinea-pigs and then produced various injuries. The 
animals died of general tuberculosis, but in no case were they able to dis- 
cover evidences of local tuberculosis at the seat of injury. 

Clinically, tuberculosis of the bones can be traced only in a small per- 
centage of the cases to a traumatic origin. It is. as Volkmann asserted long 



554 PEINCIPLES OF SURGERY. 

ago, characteristic that the traumatism is always slight, often quite in- 
significant; tuberculosis of bone, even in tubercular subjects, seldom, if 
ever, follows a fracture, as the injury in such cases is productive of such 
active cell-proliferation that will neutralize the pathogenic action of the 
bacilli which might reach the seat of injury with the extravasated blood. 
It is also possible that in many cases, at least, the attention of the patient 
or his friends is first accidentally called to an existing tubercular focus 
by the immediate effects of the injury, the latter having had no influence 
in the causation of the disease. Every child large enough to run around 
injures himself more or less (almost) daily, and yet tuberculosis of the 
bones and joints follows as a consequence only in comparatively few, and 
in such cases the essential cause must be present in the blood or tissues 
at the time the injury is received. As has been previously stated, what is 
generally regarded as local bone tuberculosis (by which we mean the ab- 
sence of recognizable tubercular lesions in other organs) is in reality a 
secondary disease, resulting from the introduction of bacilli through the 
respiratory or alimentary tract into the circulating blood, with localization 
in the bone, or the entrance of bacilli into the circulation from a preexist- 
ing, but undetectable, tubercular product, with secondary localization in 
bone. In this sense a primary, or, to use a more correct expression, a 
localized osseous or articular tuberculosis is, .according to Kummer, found 
in about 40 per cent, of the cases; in the remaining 60 per cent, depots 
are found at the same time in other organs of the body; the lung comes 
first, with 25 per cent.; other joints, 10 per <3ent.; other bones, 10 per 
cent.; lymphatic glands, 10 per cent.; peritoneum, 3 per cent.; pleura, 2 
per cent. 

Pathology and Morbid Anatomy. — The tubercle bacillus has a special 
predilection for the medullary tissue of the bones, and especially for the 
red medullary tissue in the cancellated tissue in the region of the epiph- 
yseal cartilage of the long bone. As an inflammatory affection, it is 
more correct to speak of tubercular osteomyelitis than tuberculosis of 
bone, since the medullary tissue and the blood-vessels which it contains 
are the parts that take an active part in the inflammatory process. The 
anatomical conditions of the vessels in the epiphyseal region of the long 
bones in young persons, and in the vessels of the medullary tissue, favor 
implantation of the microbes upon the vessel-wall, and they also explain 
the frequency with which localization, of the tubercular process takes 
place in this locality. The shaft of the long bones is generally exempt 
from tubercular disease with the exception of the phalanges of the fingers 
and toes and the metacarpal and metatarsal bones in children, where the 
tubercular osteomyelitis gives rise to the well-known spina ventosa of the 
old authors. As soon as embolic infection in bone has taken place a 




Fig. 185. — Caries of Fourth Metacarpal Bone before Operation. (Sanger Brown.) 



TUBERCULOSIS OF BONE. 555 

process of osteoporosis and decalcification occurs around the tubercular 
embolus or thrombus, and the preexisting medullary and connective tis- 
sues are transformed into embryonal or granulation cells, which impart 
to the product of the specific inflammation its characteristic fungous ap- 
pearance. It is not often that only a single focus of tubercular infection 
in bone is present; more frequently two or three foci appear in the same 
region simultaneously or in slow or rapid succession, and it is not unusual 
to find that two neighboring epiphyses are infected at the same time or 
during the course of the disease. In bone the granulation-tissue under- 
goes the same series of secondary degenerative tissue-changes as in the 
lymphatic glands; hence in advanced cases we expect to meet with casea- 
tion, liquefaction of the cheesy material, and suppuration in cases of sec- 
ondary infection with pyogenic microbes. The obstruction of a small 
artery by an embolus or thrombus which contains tubercle bacilli usually 
leads to necrosis and sequestration of a triangular piece of bone, which, 
in its outlines, marks the area of tissue which received its blood-supply 




Fig. 186.— Tubercular Focus near the Epiphyseal Line of the Lower End of the Femur. 

from the obstructed vessel; thus the triangular sequestra are formed that 
are so frequently met with in osteal tuberculosis of the epiphyseal ex- 
tremities. If the embolus is located on the side of the epiphyseal cartilage 
toward the joint, the base of the triangular sequestrum is directed toward 
the joint, and not infrequently projects slightly into the joint. It is 
seldom that tuberculosis of bone develops in the course of pulmonary 
tuberculosis, but pulmonary and diffuse miliary tuberculosis can be traced 
frequently to a tubercular osseous focus. The intimate relations which 
exist between the tubercular nodule in bone and the blood-vessels furnish 
a satisfactory explanation of the frequency with which systemic infection 
takes place. A person once infected with the bacillus tuberculosis is liable 
to suffer from the different forms of localized tuberculosis, and finally 
dies of pulmonary or general miliary tuberculosis. Volkmann has well 
said that a child suffering from glandular tuberculosis has a good chance 
to become the subject of osseous tuberculosis during adolescence, and to 
die of pulmonary tuberculosis before reaching the age of 30. As soon as 



556 PRINCIPLES OF SURGERY. 

the granulation process in bone reaches an adjacent vein, the tissues con- 
stituting the vein-wall undergo the same process, the bacilli reach the 
lumen of the vessel and reenter the systemic circulation, and give rise to 
miliary tuberculosis in organs which are anatomically predisposed to 
secondary infection. As long as decalcification of the surrounding bone 
goes on the infection is progressive, but as soon as osteosclerosis takes its 
place the process becomes limited: the microorganisms are shut in, as it 
were, by an impermeable wall of sclerosed bone. The most unfavorable 
conditions are created in cases in which the tubercular focus becomes the 
seat of secondary infection with pyogenic microbes, as the suppurative 
process opens up to the bacillus of tuberculosis new areas for invasion in 
which the resistance of the tissues to tubercular infection has already been 
greatly diminished. It is also during the suppurative stage that joint- 
complications are most likely to arise. The clinical history of cases of 
tuberculosis of bone, as well as the macroscopical and microscopical ap- 
pearances of the lesion, are typical of tuberculosis as found in other oragns. 
The crucial test which proves the tubercular character of most of the 
chronic inflammatory affections of bone in children has been furnished by 
bacteriological investigations and experimental research. Most of the in- 
vestigators who have studied this subject agree that in tubercular bone 
affections it is sometimes very difficult to find the bacillus, that it is not 
found in great abundance, and that sometimes it has evaded even the most 
careful search. According to Konig, who is authority on everything that 
pertains to tuberculosis of bones and joints, all cases of osteotuberculosis 
can be arranged under four principal groups, according to the predomi- 
nating pathological conditions of the lesions: 1. The granulating focus. 
2. The tubercular necrosis. 3. The tubercular infarct. 4. Diffuse tuber- 
cular osteomyelitis. 

1. The granulating focus is found as single or multiple, round or oval, 
cavities, from the size of a millet-seed to that of a pea or hazel-nut, con- 
taining living embryonal tissue, or, if this has been destroj^ed by coagula- 
tion-necrosis and caseation, a yellowish-gray, cheesy material, or liquid tuber- 
cular pus. Minute spiculse of bone are imbedded among the granulations or 
suspended in the liquefied caseous material. Histologically, the granulation- 
material is composed of the same cell-elements as recent tubercle in other 
organs, only that, as a rule, the giant cells are more numerous and of larger 
size. If caseation has taken place the cheesy material is surrounded by a 
zone of granulation-tissue. As long as the process has not come to a stand- 
still the surrounding bone is osteoporotic, and can be easily scraped out with 
a sharp spoon. As soon as the inflammatory process has subsided the osteo- 
porotic bone becomes sclerosed and the tubercular focus is walled in and, for 
the time being, is rendered harmless. Cheesy tubercular cavities in bone 



Tl HKKCl l.OSIS OF BONK. 



557 



resemble the same condition in the lungs, only that secondary infection with 
pus-microbes is of less frequent occurrence, and on this account the cavity 
never attains such large size as in the latter organ. 

2. Tubercular necrosis necessarily follows if the infected area exceed 
the size of a hazel-nut. The non-vascular structure of the tubercular product 
and the blocking and destruction of blood-vessels during the early stages of 



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%-A4// 



Fig. 187. — Tuberculosis of Astragalus. Tu, fungous granulations and tubercle 
in spongiosa; E, remaining laminae. {Tillmanns.) 

the tubercular inflammation produce early death of the bone, corresponding 
to the limits of the inflammation, and if this exceed the resorption capacity 
of the granulations the dead tissue is not removed by absorption, and is found 
as a sequestrum as soon as it has become detached from the surrounding 
healthy bone. If the tubercular process has been rapid and the granulation- 
tissue is scanty, the necrosed bone is not osteoporotic; but if the disease has 
pursued a more chronic course, and has resulted in the production of an 




Fig. 188.— Tubercular Sequestra. (Landerer.) 



abundance of granulation-tissue, it presents a honey-combed appearance, is 
irregular in shape and in size, does not correspond with the area of the in- 
fected district, as part of it has been absorbed by the granulations. Its color 
depends on the condition of the granulations which surround it; if these 
have not undergone secondary degenerative changes it may resemble healthy 
bone, but if caseation has taken place it is infiltrated with cheesy mate- 



558 



PRINCIPLES OF SURGERY. 



rial, and then presents a grayish-yellow or yellow appearance. If the ne- 
crosed bone has undergone no reduction in size, and the granulations sur- 
rounding it are few, it remains firmly wedged in position, and under such 
circumstances it is often difficult to locate the exact boundary-line between 
it and the surrounding healthy bone or to dislodge it from its position. 

3. The tubercular infarct is only another form of tubercular necrosis, 
and is separately classified because the necrosed bone is always wedge-shaped, 
and the necrosis has been caused by the impaction of an embolus containing 
tubercle bacilli in a distal branch of a nutrient artery. The size of the vessel 
obstructed by an infected embolus will determine the extent of the necrosis. 
If the embolus is small, the area of necrosis may be increased by the blocked 
vessel becoming the seat of secondary thrombosis, obliteration of the vessel 
taking place in a proximal direction by growth of the thrombus toward the 
heart. As the cortical portion of the bone is seldom involved by a tuber- 




Fig. 189. — Tubercular Infarct in the Head of the Femur. Cartilage separated from 
the wedge-shaped sequestrum. (Volkmann.) 

cular infarct, the necrosed area is often overlooked in operations on tuber- 
cular joints unless the bone is sawn through. If the base of the wedge- 
shaped piece project into a joint that has been used, its surface will be found 
smoothly polished by the movements in the joint. Separation of the seques- 
trum takes place more slowly than after suppurative osteomyelitis, the proc- 
ess requiring often, according to the size of the sequestrum and the activity 
of the inflammatory process, months and years for its completion. If the 
granulations which surround the sequestrum do not undergo cheesy degen- 
eration, the bone becomes imbedded and fits accurately into the cavity, and 
if the surrounding zone of granulation is converted into connective tissue 
it may become permanently encapsulated; but even from such an apparently 
healed depot local and general infection can occur at any time. 

4. The diffuse form of tubercular osteomyelitis is quite rare. The 
pathological and clinical characteristics of this form of local tuberculosis 
consist in the rapid local extension of the affection and the danger to life 



TUBERCULOSIS OF BON E. 559 

from general infection. On making a longitudinal section through a long 
bone affected by diffuse tubercular osteomyelitis, we observe conditions 
which closely resemble acute suppurative osteomyelitis. We find large, 
irregular, often multiple areas of a yellowish-white infiltration with multi- 
ple foci of liquefied cheesy material. The infection extends, as in cases of 
suppurative osteomyelitis, along the blood-vessels and Haversian canals to 
the periosteum, resulting in diffuse plastic periostitis with the formation of 
irregular, diffuse masses of bone. In these cases there is no tendency to lim- 
itation in the formation of sequestra, but rather a tendency to spread in- 
definitely, and to invade even the medullary tissue of the shaft. Patients 
suffering from this form of tubercular osteomyelitis are exposed to the dan- 
gers of a fatal general tuberculosis if the infected tissues are not removed by 
a timely and thorough operation. In operating it is important to recognize 




Fig. 190. — Tubercular Debris from Caseated Nodule. Tubercle bacilli mixed with necrotic 
cell-elements. (Stained by Ziebl's carbol-fucbsin and Loeffler's methylene-blue.) 

this form, since it requires more radical measures: either amputation or very 
extensive excision of the entire thickness of the affected bone. Local opera- 
tions such as will meet the indications in the other varieties of osteotuber- 
culosis are of no avail. With the exception of this form of tuberculosis of 
bone the periosteum seldom participates in the tubercular inflammation. 
When the dry granulating focus reaches the periosteum, a small, soft, elastic, 
limited granulation swelling forms: first under the periosteum, later outside 
of it. It is characterized by slow growth, comparatively little pain, slight 
tenderness, and a tendency to remain stationary for a long time. If, how- 
ever, the central focus has become cheesy, and the liquefied cheesy material 
comes in contact with the periosteum and the paraperiosteal tissues, a large 
tubercular abscess forms in a short time. As soon as the periosteum has been 
perforated the cheesy material infects the connective tissue, which then takes 



560 PRINCIPLES OF SURGERY. 

an active part in the formation of the tubercular abscess. Before such an 
abscess ruptures spontaneously the skin overlying it becomes tubercular and 
presents, at the point of perforation, the appearance of lupus. 

Symptoms and Diagnosis. — The general symptoms are often no indica- 
tion of the existence or extent of the local disease, as patients with quite 
extensive osteotuberculosis may present every appearance of perfect health. 
More than twenty years ago Konig called our attention to the fact that a 
slight rise in the temperature is frequently present even in cases of limited 
local tuberculosis. If the thermometer show a normal morning temperature 
and a slight rise toward evening, if not more than half a degree Fahrenheit, 
but continued for weeks, it indicates a careful search for a local tubercular 
focus. Progressive anaemia is always an unfavorable symptom, as it indi- 
cates either the presence of additional foci in important organs or accom- 
panies the exhaustive purulent discharges after secondary infection with 
pus-microbes. The occurrence of mixed infection, with or without a direct 
infection-atrium, is usually announced by a high temperature and other 
symptoms of septic infection. The local symptoms vary according to the 
location, condition, and size of the tubercular focus and the presence or ab- 
sence of complications. 

1. Pain. — Pain is an almost constant symptom, but its intensity is sub- 
ject to great variation. Unlike in acute suppurative osteomyelitis, the in- 
flammatory product does not give rise to the same degree of tension; hence 
pain is not so severe. The primary exudation in tubercular inflammation is 
.always scanty, and the inflammatory product is composed mostly of granu- 
lation-tissue derived from preexisting cells; at the same time the surround- 
ing bone-tissue becomes osteoporotic, consequently tension is, to a great 
•extent, avoided and pain is either slight or entirely absent. Children suf- 
fering from spina ventosa complain of little pain, although a phalanx of a 
finger may be almost completely destroyed by a tubercular osteomyelitis. 
In such cases the granulation-tissue is formed slowly, the compact layer of 
the bone is rendered osteoporotic, and generally yields to the intraosseous 
pressure and expands perhaps to twice its normal thickness; pain is slight 
or entirely absent, because no great intraosseous tension has occurred. That 
tension or pressure greatly aggravates pain in osseous tuberculosis is one of 
the most familiar facts in surgery. Pain is promptly relieved in a case of 
tubercular spondylitis by suspension and rest in the recumbent position, 
and greatly aggravated by flexion of the spinal column, which necessarily 
produces pressure upon the bodies of the inflamed vertebras. In osteoar- 
thritis of the large joints pain is relieved by rest and extension, and is always 
increased by use of the limb or by pressing the inflamed articular surfaces 
against each other. It may be stated, as a rule, that the intensity of the pain 
bears a direct relationship to the acuteness of the inflammatory process. The 



TUBERCULOSIS OF BONE. 561 

pais is intermittent and more severe during the night. The nocturnal ex- 
acerbation of the pain, as evidenced in children by restlessness during sleep, 
moaning, grinding of teeth, and horrible dreams, is often one of the first 
symptoms which excites suspicion of the existence of osteotuberculosis. The 
pain is not always referred to the seat of lesion. Tubercular osteomyelitis of 
the head and neck of the femur gives rise to pain in the region of the knee- 
joint, and children suffering from tuberculosis of the spine usually refer all 
the suffering to the pit of the stomach or to some other part of the abdomen 
supplied with nerves that take their exit from the spinal canal at a point 
corresponding to the inflamed vertebra. 

2. Tenderness. — The presence of tenderness over a point corresponding 
to a tubercular focus in the interior of a bone is one of the surest indications 
of the existence of osteotuberculosis. In many cases of epiphyseal tubercu- 
losis patients have been treated for some supposed lesion in the adjacent 
joint simply because this symptom was not carefully searched for, or, if dis- 
covered, its significance was misinterpreted. In such cases the existence of 
a circumscribed point of tenderness in the epiphyseal line and the absence of 
lesions in the joint will enable the surgeon to locate accurately a focus in the 
interior of a bone. If more than one focus is present in the epiphyseal ex- 
tremity of a long bone, the number of tender points will correspond with the 
number of foci in the bone. Whether a central focus in a bone could be 
always recognized by relying upon this symptom is somewhat doubtful, but 
usually the foci are located sufficiently near the surface of the bone to give 
rise to tender points, which can be readily located by finger-pressure. 

3. Swelling. — External swelling is absent until the atrophic layer of 
compact bone yields to the intraosseous pressure, as may be seen in advanced 
cases of spina ventosa, or until by pressure atrophy over the centre of the 
focus the compact layer is perforated, and a soft, circumscribed, boggy swell- 
ing forms underneath the periosteum. If the granulation-tissue has retained 
its vitality the extraosseous swelling increases very slowly in size, and there 
is no tendency to diffuse infection of the connective tissue after the granu- 
lations have reached the paraperiosteal tissues. Pseudofluctuation is gener- 
ally present, and many such granulating foci at this stage have been care- 
lessly incised under the mistaken diagnosis of abscess. If the central focus 
has undergone caseation before the periosteum is perforated, then the para- 
periosteal tissues become rapidly infected, and a tubercular abscess, such as 
has been described before, develops in a short time. The abscess wanders 
away from the place where it originated in directions offering the least re- 
sistance, along preformed anatomical spaces and in obedience to the law of 
gravitation. The size of such an abscess is, absolutely, no indication of the 
extent of the primary lesion in the bone, as a minute focus may be the cause 
of a large abscess and a small abscess may mark the location of an extensive 



562 PKINCIPLES OF SURGERY. 

primary lesion. (Edema is usually not well marked, even if the abscess is 
large, unless secondary infection with pyogenic microbes has occurred. The 
diffuse form of tubercular osteomyelitis is always attended by a plastic osteo- 
myelitis, and, consequently, the early appearance of external swelling is one 
of the points to be taken into consideration in differentiating between the 
different forms of osteotuberculosis. The swelling that attends tuberculosis 
in bones deeply seated — as the vertebrae, hip-joint, and pelvic bones — does 
not become apparent until the existence of a tubercular abscess indicates the 
probable seat of the primary lesion. 

4. Redness. — The skin over a tubercular focus in the interior of a bone 
or over a tubercular abscess presents a normal appearance until it has be- 
come infected and shows other unmistakable signs of tuberculosis. This 
does not occur until the granulations have permeated the deeper portions of 
the skin, or until the caseous material has only the skin for its covering. 
Under such circumstances the skin presents a dusky-red hue, owing to im- 
paired capillary circulation, and becomes more and more attenuated by 
pressure atrophy and destructive changes until it finally yields to the press- 
ure from beneath, and spontaneous evacuation of the contents of the abscess 
takes place. If the subcutaneous product is composed of granulation-tissue 
the undermined skin, after perforation has taken place, is destroyed by de- 
grees and the part presents the appearance of lupus. 

5. Atrophy of Limb. — Muscular atrophy is almost a constant symptom 
in osteotuberculosis as well as in tubercular synovitis. This atrophy is not 
caused altogether by inactivity of the limb, and it appears to be due in part, 
at least, to trophoneurotic lesions. 

Besides a careful study of the clinical history, several diagnostic meas- 
ures may be resorted to in doubtful cases to enable the surgeon to make a 
positive diagnosis. 

Means of Differential Diagnosis. — (a) Akidopeurastik. — Exploration 
of a doubtful swelling with a strong steel needle was introduced by Mid- 
deldorpf for the purpose of ascertaining the consistence and probable struct- 
ure of the tissues composing the swelling. He called this simple procedure 
akidopeurastik,. The presence of a tubercular focus in the interior of a bone 
can often be demonstrated by this aid to diagnosis before any external swell- 
ing has appeared. A strong needle of an hypodermic syringe can be used 
for exploring a bone the density of which has been diminished by chronic 
inflammation, if this latter has not been followed by osteosclerosis. During 
the active stage of osteotuberculosis the bone for a considerable distance 
around the focus is osteoporotic, and can be readily penetrated by a strong, 
sharp needle. The exploration should be made under strict antiseptic pre- 
cautions. The puncture is made in the centre of the tender area, and in a 
direction corresponding to the probable location of the central focus. If the 



IUBEBCULOSIS OF BONK. 563 

needle meet with any considerable resistance in the bone, it is advanced by 
rotary movements; the arrival of the point in the granulating centre or 
caseous locus is announced by a sudden loss of resistance. By advancing 
the needle sufficiently to touch the opposite side of the cavity its probable 

an be ascertained. 

(b) Exploratory Puncture, with Aspiration. — If the needle of an ex- 
ploratory or hypodermic syringe is used to make the akidopeurastik, explora- 
tion of the bone may be followed by removing some of the contents of the 
cavity by aspiration for examination. If the tubercular product has under- 
gone caseation and liquefaction some of the cheesy material can be removed 
by aspiration, and the nature of the lesion may then be revealed by positive 
demonstration. If still further evidence is required, a guinea-pig may be 
inoculated with the same needle, which still contains enough of the material 
to produce a positive result in the animal. If the cavity contain granulation- 
tissue little fragments of this can be drawn into the needle, and with these 
inoculation experiments for diagnostic purposes can be made. Search 
for the bacillus tuberculosis in the products removed is a very important 
diagnostic resource. In tubercular necrosis it may be possible to detect 
the presence of the sequestrum and ascertain its mobility by exploratory 
puncture. If a tubercular abscess has formed, the character of the con- 
tents of the swelling may be ascertained by using the exploratory syr- 
inge, and the nature of the primary cause demonstrated, if need be, by 
injecting the material aspirated into the subcutaneous tissue or peri- 
toneal cavity of a guinea-pig. In the differential diagnosis of tubercu- 
losis of bone, it is necessary to exclude synovial tuberculosis, sarcoma, 
echinococcus cyst, rachitis, suppurative osteomyelitis, and syphilis. Many 
cases of primary tuberculosis of bone have been mistaken for synovial tu- 
berculosis, and vice versa. Primary tuberculosis of bone frequently results 
in contractures of joints without direct implication of the joint, and this has 
often led to a wrong diagnosis. In primary synovial tuberculosis the first 
pathological changes occur in the joint, and no tender points will be found 
in the epiphyseal regions. In osteotuberculosis not complicated by an ex- 
tension of the disease to the adjacent joint the first symptoms are referred 
to the lesion existing in the interior of the bone, and it is usually not diffi- 
cult to ascertain the existence of circumscribed points of tenderness which 
correspond to the location of the foci. Periosteal sarcoma is, from the be- 
ginning, an extraosseous product. Central sarcoma, as a rule, increases more 
rapidly in size than a tubercular swelling, and is often the seat of pulsations 
and a blowing sound which can be heard by auscultation. Central sarcoma 
is often the cause of a pathological fracture, while this accident is exceed- 
ingly rare in osteotuberculosis. Echinococcus of bone is an exceedingly rare 
affection, but, as it may simulate osteotuberculosis, differential diagnosis 



564 PRINCIPLES OF SURGERY. 

must be based on an exploratory puncture, which will yield a clear serum 
containing the characteristic hooklets in the former instance, and granula- 
tion-tissue or the products of caseous degeneration in the latter. Eachitis 
gives rise to swelling and pain in the epiphyseal regions; but this affection 
is not limited to one or two bones, and affects almost every bone in the body 
alike. Epiphyseal multiple osteomyelitis is an acute or, at least, subacute 
affection, and results early in the formation of purulent foci, and is often 
attended by epiphyseolysis. The virus of syphilis has a special predilection 
for the periosteum, while this structure is almost immune to primary tuber- 
cular affections. In 95 out of every 100 cases chronic inflammation in bone 
means tuberculosis, and, unless there are special reasons which should render 
the diagnosis doubtful, it is safe to adopt a treatment adapted for tubercular 
osteomyelitis in almost every case where the symptoms point to a chronic 
inflammation and the existence of a tumor or parasitic growth can be ex- 
cluded. 

Prognosis. — On the whole, the prognosis is more favorable in cases of 
osteotuberculosis than if the tubercular infection is located in the skin, a 
joint, lymphatic gland, or any of the internal organs. Spontaneous healing 
of a tubercular focus in bone is possible under favorable conditions. Every- 
thing that adds to the patient's strength and power of resistance to the mi- 
crobic infection adds to the possibility of such a favorable termination. If 
the patient is well nourished, and, above all, if the blood is in a normal con- 
dition, limitation of the disease may occur before caseation has taken place; 
and if cheesy material has formed, and it can be removed by operative inter- 
ference, the prospects of a permanent recovery are good. It must be, how- 
ever, admitted that every person who has suffered from an attack of osteo- 
tuberculosis during childhood or youth, even if an apparent perfect cure has 
been effected spontaneously or by operative measures, is always in danger of 
becoming the subject of reinfection at any subsequent time. The spores of 
the bacillus of tuberculosis may remain in a latent condition for an indefinite 
period of time in the cicatrized primary lesion, to become a cause of subse- 
quent danger as soon as the local or general conditions enable them to ex- 
ercise their pathogenic properties. Healing by cicatrization is possible in 
the small granulating foci so long as the coagulation-necrosis is limited and 
no caseation has occurred. In such cases the embryonal cells are converted 
into permanent connective tissue and the small fragments of bone are re- 
moved by absorption, while the bone around the cicatrix becomes sclerosed. 
If caseation has occurred, but the cheesy material has not undergone lique- 
faction, capsulation of the tubercular product can take place by the wall of 
granulation-tissue lining the cavity becoming converted into cicatricial tis- 
sue, forming a capsule, which, for the time being at least, mechanically pre- 
vents the local extension of the disease. Small sequestra may become im- 



TUBERCULOSIS OF BOH E3. 565 

bedded in a connective-tissue capsule in a similar manner. If the seques- 
trum is large it will act like every other foreign infected body, and sooner 
or later require an operation for its extraction. If the tubercular process has 
extended to a joint, the prognosis is more grave, and the chances for a spon- 
taneous recovery are much diminished. The prognosis is always more grave, 
other things being equal, if the bone affected is so located that removal of 
the primary focus by operative treatment is anatomically impossible. The 
danger to life and the probability of local extension are always greater if the 
granulation-tissue has been destroyed by coagulation-necrosis and caseation, 
as the granulation-tissue is one of the means by which regional and general 
infection are retarded or prevented. The danger to life is imminent if a large 
tubercular abscess has become infected with pus-microbes, as the secondary 
infection results in destruction of the granulation-tissue lining the cavity, 
which favors the local and general extension of the tubercular infection, and 
at the same time brings sepsis, exhaustion from profuse suppuration, and 
amyloid degeneration of important internal organs as additional elements of 
danger. The prognosis is always more grave in persons advanced in years 
than in children, as limitation of the disease occurs more frequently in the 
latter. 

Treatment. — The medical treatment in patients suffering from osteo- 
tuberculosis must be tonic and supporting. Dietetic and hygienic treatment 
is of more value than the administration of drugs. Sea-bathing and change 
of climate will often accomplish more than bitter tonics, iron, quinine, ar- 
senic, and codliver-oil. The prolonged internal administration of guaiacol 
or one of its preparations should always be resorted to. The local treat- 
ment, short of a radical operation, must consist in the use of such means as 
will aid the natural resources in effecting limitation of the tubercitlar proc- 
ess, of which the most important is 

1. Physiological Rest. — The importance of securing for the inflamed 
part, as near as can be done by mechanical support, absolute physiological 
rest cannot be overestimated. The process of repair in a tubercular focus 
often meets with great and insurmountable difficulties. The embryonal cells, 
of low vitality almost from the beginning, are poisoned as soon as born with 
the toxins of the bacillus of tuberculosis, and consequently are converted 
into tissue of a higher type only under the most favorable conditions. The 
non-vascularity of tubercle-tissue is another cause why the inflammatory 
product so seldom takes an active part in the process of repair. The first 
indication in the treatment of a tubercular osteomyelitis is to secure for the 
part a favorable condition of the circulation, which can only be done by 
securing rest. The most efficient way to procure rest, not only for the dis- 
eased part, but for the entire body, is to confine the patient to bed; but, as 
these affections are noted for their chronicity, lasting for months and years, 



566 PRINCIPLES OF SURGERY. 

enforced rest by this method would seriously impair the general health, and 
on this account it is advisable, in the majority of cases, to resort to one of 
the numerous mechanical appliances which will immobilize the part; while, 
at the same time, the patient can avail himself of the benefits to be derived 
from out-door air and change of scenery and surroundings. 

In tuberculosis of the spine the most efficient treatment during the 
acute stage is the dorsal recumbent position upon a Eauchfuss sling, fol- 
lowed by Sayre's plaster-of-Paris jacket, applied while the patient is partly 
suspended, which answers a more useful purpose than any of the numerous 
complicated apparatuses which have been as yet devised. To apply the jacket 
properly requires a great deal of experience and the exercise of considerable 
skill. In many communities this method of treatment has become un- 
popular, both among physicians and the laity, from the bad results caused 
by improper applications of the jacket. Hyperextension must be avoided, 
and the patient must be instructed to extend himself only until pain is re- 
lieved and riot beyond this point. The bony prominence at the seat of curva- 
ture must be carefully protected against pressure by applying on each side 
a firm pad sufficiently thick to prevent contact of the jDrojecting spinous 
processes with the plaster cast. The plaster bandages themselves must be 
applied smoothly, so that after extension is removed the jacket will closely 
fit the unequal surface of the body. Another matter of great importance 
is to see the patient from time to time, in order to determine whether the 
jacket causes injurious pressure at any point, which, if this should be the 
case, is remedied at once, either by cutting out that portion of the jacket 
which has caused the decubitus or by applying a new one. In tuberculosis 
of any of the bones of the extremities rest can be secured most efficiently by 
immobilizing the limb in a plaster-of-Paris dressing. The splint must always 
include one or more of the adjacent joints. Undue constriction of the limb 
is prevented by interposing between it and the splint a thin layer of salic- 
ylized cotton. If the disease affect any of the bones of the lower extremities 
the patient must not be allowed to walk without crutches. 

2. Ignipuncture. — During the early stages of osteotuberculosis excel- 
lent results have been obtained by ignipuncture : a method of treatment 
devised by Eichet in 1870. If a tubercular focus can be accurately located, 
this method of treatment should receive a trial, as it is not attended by any 
risks and frequently effects a permanent cure. The field of operation is thor- 
oughly disinfected, and, with the needle-point of a Paquelin cautery heated 
to a dull red heat, the soft tissues and bone are perforated. In making 
the perforation it is necessary to advance the point slowly and to remove it 
from time to time and revive the heat in order to prevent impaction of the 
point. The entrance of the point of the instrument into the cavity or tuber- 
cular focus can be readily felt, as resistance at that moment is suddenly 



TTJBEBGULOSIS OF BONE. 567 

diminished. The therapeutic effect of ignipuncturc is threefold: 1. The 
tonne] made establishes free drainage and relieves promptly the intraosseous 
tension. 2. At hast a portion of the infected tissue is destroyed by the heat. 
3. A plastic osteomyelitis is excited in the vicinity of the track and in the 
cauterized portion of the cavity, which exerts a favorable influence in bring- 
ing about limitation of the disease, or even in effecting a final cure. Through 
the opening made iodoform can be introduced into the cavity, which offers 
additional advantage in treating osseous foci successfully by this procedure. 
To insure a successful issue it is absolutely necessary to prevent infection with 
pus-microbes through the opening by making the operation under strict 
aseptic precautions, and protecting the puncture- with an efficient antiseptic ab- 
sorbent dressing until it is completely closed by cicatrization and epidermiza- 
tion. Ignipuncture is most useful in the treatment of accessible foci in the 
epiphyseal extremities of the long bones and during the early stages of 
tuberculosis of the wrist and tarsus. In incipient tuberculosis of the tarsus 
I have repeatedly obtained a satisfactory and permanent result by making 
an opening through the entire tarsus from side to side, in a line of the dis- 
ease, by inserting the point from each side, the two tunnels meeting in the 
centre. Ignipuncture always relieves the pain promptly, and the track made 
is completely closed by permanent tissue in the course of a few weeks. 

Parenchymatous Injections of Iodoform. — In foci accessible to punct- 
ure parenchymatous injections of a 10-per-cent. iodoform-glycerin emulsion 
deserve a faithful trial. This method of treatment is of special value in cases 
in which the bone affection has resulted in the formation of a tubercular 
abscess. In such instances not only the abscess-cavity, but the tissues at the 
primary focus, should be iodoformized. 

3. Radical Operation. — (a) Removal of Limited Foci. — The radical 
treatment of tuberculosis of bone consists in the complete removal of the 
infected tissues by operative interference. The success which follows this 
treatment is most marked in cases where caseation has not taken place, — 
that is, in the granulating form, — and in other forms where the operation is 
performed before extensive secondary pathological conditions have occurred. 
The operation is indicated as soon as a positive diagnosis can be made, and 
after the milder measures have proved useless in arresting the progress of 
the disease. Timely surgical interference in osteotuberculosis is not only 
calculated to become the surest means of preventing general infection, but 
it also has for its object the limitation of the disease by the removal of the 
primary cause, and by accomplishing these objects it becomes at once a 
proprniactic as well as a curative measure. If a tubercular focus or foci can 
be removed by a radical operation before the adjacent joint has become in- 
fected, then the operation has not only been successful in effecting a per- 
manent cure, but it has also been instrumental in preventing the extension 



568 PRINCIPLES OF SURGERY. 

of the disease to the joint. If the operation is undertaken at a time, as it 
should be, before any external swelling has appeared, the surgeon must be 
guided in finding the focus by searching for tender points, aided, if neces- 
sary, by exploratory punctures. -As in epiphyseal tuberculosis the foci are 
always near a joint, the incision for exposing the bone should be made in 
such a manner as to avoid opening the joint. A case of central tuberculosis 
of the neck of the femur, as shown in Fig. 191, was subjected to a successful 
extraarticular operation by Volkmann. If the focus be so close to the joint 
as to make it necessary to remove bone underneath the insertion of the cap- 
sule or ligaments of the joint, it is advisable to lift the periosteum with the 
joint-structures from the bone to some distance from the incision, and in this 
manner avoid injury to the joint. The bone overlying a tubercular focus or 
abscess is usually softened and easily removed with a small, hollow chisel. 
The limb should always be rendered bloodless by using Esmarch's con- 




Fig. 191.— Central Tuberculosis of the Neck of the Femur. (Volkmann.) 

strictor, so that the operator can identify the tissues as they are being re- 
moved during the operation. If, after tunneling the bone for a considerable 
distance, the focus be not found, it is advisable to make from this track 
exploratory punctures in different directions with a small perforator until 
the cavity is found, which is then freely exposed with the chisel. As soon 
as this has been done the sharp spoon is used, with which the necrosed bone, 
granulation-tissue, or cheesy material is removed. The osteoporotic bone in 
the immediate vicinity of the cavity is removed in a similar manner, and the 
surgeon must assure himself, by repeated examinations of the tissue re- 
moved, that healthy tissue has been reached before the sharp spoon is laid 
aside. 

If any doubt remain whether all of the infected tissue has been re- 
moved, it is better to resort to ignipuncture, perforating the bone at different 
points to the depth of a few lines with the sharp point of a Paquelin cautery 



TUBERCULOSIS OF JOINTS. 569 

in addition to the curetting. This procedure will destroy at least some of 
the bacilli which might have remained, and will incite a plastic osteomye- 
litis that Avill effectually resist the pathogenic action of such microbes that 
still remain. After the cavity has been thoroughly irrigated with an anti- 
septic solution it is dried, iodoformized, and packed with antiseptic decalci- 
fied bone-chips. The periosteum is separately sutured over the bone-pack- 
ing, sufficient space being left to insert, at the lower angle of the wound, a 
few threads of catgut to serve as a capillary drain. The remaining tissues 
are included in the superficial sutures and an antiseptic dressing applied. 
The limb must be immobilized by applying a well-padded posterior splint. 
If all the infected tissues have been removed and no infection with pus- 
microbes have taken place during or after the operation, the wound unites 
under one dressing in from one to two weeks, and the definitive healing of 
the cavity is completed in the course of three to six weeks, according to the 
condition and age of the patient and the size of the cavity. The packing of 
such cavities with iodoformized decalcified bone-chips is an important ele- 
ment in the prevention of a local recurrence and general infection, and in 
securing satisfactory healing of the wound and complete restoration of the 
lost parts. Should suppuration follow the operation, secondary implanta- 
tion with decalcified bone-chips can be done successfully as soon as suppura- 
tion has ceased, and the cavity can be made thoroughly aseptic. 

(b) Excision of Portion of Shaft. — This operation is only indicated in 
some cases of diffuse tubercular osteomyelitis where amputation is consid- 
ered unnecessary. Eesection of the entire thickness of the shaft of a long 
bone for tuberculosis should be limited to the radius, ulna, fibula, tibia, the 
metatarsal and the metacarpal bones. Extirpation of the entire bone affected 
is frequently necessary in tuberculosis of the wrist- and ankle- joints. 

(c) Amputation. — Amputation is often the only choice in the treat- 
ment of diffuse tubercular osteomyelitis, as it offers the only chance to effect 
complete eradication of the disease, and to protect the patient against general 
infection. It is contraindicated in the other forms of osteotuberculosis, 
unless complicated by tuberculosis of an adjacent joint, and even in such 
instances it is limited to cases that have passed beyond the reach of a typical 
or atypical resection. 

TUBERCULOSIS OF JOINTS. 

Tuberculosis of joints, chronic fungous arthritis, strumous arthritis, 
and tumor albus are terms that even now are being used synonymously to 
indicate a form of inflammation of joints which clinically is characterized 
by its chronic course and the absence of acute signs of inflammation. This 
affection is by far the most common joint disease, so much so that Konig 
states that in surgical clinics the surgeon will have 100 cases of tuberculosis 



570 PRINCIPLES OF SURGERY. 

of the joints to deal with to one of the other classes of inflammation, such 
as gonorrheal, syphilitic, suppurative, osteomyelitic, rheumatic, or the meta- 
static inflammations subsequent to acute infectious diseases. 

Etiology. — We distinguish, as to origin, between primary synovial and 
primary osteal tuberculosis of the joints. If the primary focus is in the 
bone the disease usually extends to the joint by direct progression of the 
process to the structure of the joint. In primary synovial tuberculosis the 
bacillus is conveyed through the circulation, and localization takes place in 
the synovial membrane. 

Max Schiiller proved experimentally, in animals infected with tubercle 
bacilli, — for instance, through the respiratory tract, — that a slight trau- 
matism to a joint would determine localization, by way of the circulation, 
to the injured part, and that a tubercular synovitis or panarthritis would 
follow. The same author makes the statement, based on the results of his 
experiments, that a slight injury to a joint in a person who has bacilli float- 
ing in his blood would determine localization, commonly in the form of a 
synovial tuberculosis. Clinically, tuberculosis of joints has been traced in 
56 per cent, of the cases to traumatism by a direct blow to a joint, or dis- 
tortion, or overexertion. It is characteristic that the traumatism is always 
slight; a severe injury, causing intraarticular fracture, is very rarely fol- 
lowed by tuberculosis, for the same reasons that severe injuries do not pro- 
duce the disease in bone and other organs. It may be stated that, as to the 
relative frequency of the two forms of infection, it has been shown that pri- 
mary osteal tuberculosis occurs two or three times as often as the primary 
synovial. Tuberculosis of joints is always closely related to the same disease 
in bone, because, when it does not follow the latter as a secondary lesion, 
the primary synovial disease not seldom implicates the adjacent bone from 
direct, extension of the infection from the fungous synovial membrane 
to the subjacent bone structure. Synovial tuberculosis is more frequent in 
the adult than in children. Primary infection of a joint is possible only 
through a wound, as in the case referred to under the head of "Inoculation- 
tuberculosis." Tubercular infection of an intact joint presupposes the en- 
trance of the bacillus of tuberculosis through the respiratory tract or ali- 
mentary canal, or through some external infection-atrium into the systemic 
circulation, or the diffusion of bacilli through the same channel from some 
preexisting tubercular focus, and the localization of floating bacilli in the 
synovial membrane by capillary embolism or by mural implantation. A 
simple tubercular nodule over the surface of the synovial membrane may 
lead, in a comparatively short time, to diffuse tuberculosis over the entire 
surface of the joint by local dissemination of the microbes, in which the 
synovial fluid and the movements of the joint play an important part. In 
the osteal form of tuberculosis of joints the infection extends from the bone 



II BERCULOSIS OF JOIN CS. 



:.; 1 



to the joint ai once, in cases where the primary disease is the resull of in- 
farction, as the base of the wedge-shaped piece of the necrosed bone com- 
municatee directly with the joint; while infection of the joint occurs sec- 
ondarily, in cases o\' granulating foci and tubercular necrosis, by perforation 
of the tubercular product into the joint. When the foci are located close to 
the articular cartilage this must be destroyed before the joint is invaded, 
the cartilage forming a barrier that may sometimes prove sufficient to resist 
invasion. In case a focus is located at the surface of a joint, where the bone 
is not covered with articular cartilage, the thin periosteum and the synovial 
membrane covering it are more easily perforated, and consequently second- 
ary synovial tuberculosis is more liable to follow. The most complicating 
condition may arise if a tubercular focus is located at the insertion of the 
capsule of a joint. It may then open into and outside of the joint simul- 




Fig. 192.— Tuberculosis of Lower Epiphysis of Femur, with Two Sequestra (a, a) 
and Perforation into Knee-joint. (Weber.) 



taneously, or the one or the other, the integrity of the joint depending on 
the few lines of space occupied by the capsule. 

Pathology and Morbid Anatomy. — In synovial tuberculosis a series of 
pathological changes are initiated in which all the structures of the joint 
are finally concerned, namely: the synovial membrane, parasynovial tissues, 
articular cartilage, and lastly the bone. The tubercle-nodule in the synovial 
membrane presents, under the microscope, the same histological structure as 
in other tissues. When the synovial surface has become the seat of diffuse 
tuberculosis the tissues undergo the same pathological changes as during the 
first stage of tuberculosis in other organs, and it is the characteristic granu- 
lation-tissue that has given to this form of arthritis the names of fungous 
synovitis and synovitis hyperplastica granulosa. During the early stages of 
the disease the surgeon meets with two distinct varieties; in one the tuber- 



572 PKINCIPLES OF SUKGEKY. 

cular infection produces a pulpy condition of the entire synovial sac, with 
little or no effusion into the joint, the swelling being due entirely to the 
presence of a thick layer of granulation-tissue: the true tumor alius of the 
old writers. This form of tuberculosis gives rise, at an early stage, to ex- 
tensive deformity of the joint, flexion, rotation, and, in the case of the knee- 
joint, partial dislocation of the tibia backward. In the other variety the 
fungous granulations are less marked, but a copious effusion takes place into 
the joint, which simulates a catarrhal synovitis, until time and the effect of 
treatment enable the surgeon to make a correct differential diagnosis. In 
this form Konig assures us that he has never observed a tendency to flexion 
or any other form of displacement of the joint-surfaces. If suppuration take 
place, which is not very often the case, it begins in the granulations which 
cover the synovial membrane, and the pus accumulates in the cavity of the 
joint until perforation of the capsule takes place. During the suppurating 
process the granulations are destroyed and the tubercular infection pene- 
trates deeper, and, as during the destructive process blood-vessels are de- 
stroyed, the patient is exposed to the additional risks of general infection. 
If a tubercular joint open spontaneously, or is incised without observing 
strict aseptic precautions, the additional infection from without leads to 
the most serious consequences, as under these circumstances pus-microbes 
are brought in contact with a surface that has been admirably prepared by 
the bacillus of tuberculosis for suppurative and septic processes. 

Pathological Varieties of Joint Tuberculosis. — Tubercular inflammation 
of the synovial membrane of joints results in different gross pathological 
conditions that serve as a basis for classification into: 1. Pannous hyper- 
plastic synovitis. 2. Tuberous hyperplastic synovitis or papillomatous plas- 
tic synovitis. 3. Granular or fungous hyperplastic synovitis. 4. Tubercular 
articular empyema. 

1. Pannous Hyperplastic Synovitis. — The tubercle-nodules are ex- 
tremely small, rarely visible to the naked eye, and widely disseminated over 
the entire or greater portion of the synovial sac. The synovial membrane is 
only moderately thickened, but quite vascular. From the border of the carti- 
lage a thin, vascular layer of granulations approaches the centre of the sur- 
face of the joint somewhat in the manner a pannus invades the cornea. This 
form of synovitis was first described by Hueter. 

2. Tubercular Plastic Synovitis or Papillomatous Plastic Synovitis. — 
The tubercular inflammation results in the formation of subsynovial fibrous 
masses, which may attain the size of a walnut, protruding into the joint and 
filling, for example, the suprapatellar recess of the knee-joint, with simple 
irritative synovitis or pannous synovitis in the rest of the cavity. The tuber- 
cular infection in such cases is limited, and the removal of the fibrous swell- 
ing results in a permanent cure. In other cases of the same type of inflam- 



TUBER< l LOSIS OF JOIN rS. 

mation the foci are numerous, resulting in papillomatous plastic synovitis, 
where the whole inner surface of the synovial membrane is covered with 
sessile or pedunculated papillomatous growths, small and rather uniform in 
some of which may become detached, when they constitute the so-called 
rice-bodies. 

3. Granular Fungous Hyperplastic Synovitis. — In this variety of joint 
tuberculosis the synovial membrane is affected throughout, being consid- 
erably thickened and hyperaemic, and covered by a more or less thick layer 
of velvety granulations. The ligaments and paraarticular structures are 
affected at a comparatively early stage, and thus is formed the thick, cedema- 
tous mass of tissue, usually of a gelatinous appearance, in which here and 
there cheesy foci are found. 

Any of the foregoing forms of tubercular synovitis may give rise to the 
transudation of serum or a sero-fibrinous fluid into the joint: the tuber- 
cular hydrops of Konig. As a rule, the serous effusion is most copious in 
cases where the synovial membrane has undergone the least change; that is, 
in pannous hyperplastic synovitis. In tuberous and papillomatous synovitis 
the effusion is itsually scanty, and in fungous synovitis attended by the for- 
mation of massive granulations it is absent, as a rule. The effusion into the 
joint, in tubercular hydrops, is either a thin, clear synovia, or it is rendered 
slightly turbid from the admixture of leucocytes and the products of coagu- 
lation-necrosis, or, if the effusion is of a sero-fibrinous character, it contains 
shreds of fibrin. The rice-bodies {corpora amylacece), so frequently found in 
tubercular joints, are composed of soft masses of fibrin or they are detached 
papillomata. That these bodies are a tubercular product I have repeatedly 
satisfied myself by inoculation experiments. 

4. Tubercular Articular Empyema (Konig). — The tubercular abscess of 
joints is an advanced stage of the other varieties of tubercular synovitis. The 
inside of the capsule is covered with a loosely adherent tuberculous mem- 
brane, similar to that in tubercular abscesses. The superficial granulations 
which compose this membrane have undergone degenerative changes. Out- 
side of this membrane the tissues are diffusely infiltrated with miliary 
tubercles, but the infection does not extend beyond the synovial membrane. 
The fluid in the joint, like in all tubercular abscesses, is not pus, but serum, 
in which we find suspended the products of coagulation-necrosis. With the 
extension of the tubercular process beyond the limits of the synovial sac, 
the articular cartilage and, finally, the bone are successively- attacked. The 
articular cartilage takes no active part in the inflammatory process; it is 
detached and removed by the granulations. An osseous focus in contact with 
the cartilage usually makes a circular defect through which the granulations 
or cheesy material can be seen. The cartilage covering a tubercular infarct 
is rapidly destroyed, and is mechanically detached in smaller or larger frag- 



574 PRINCIPLES OF SURGERY. 

ments. In primary tuberculosis of the synovial membrane the process usu- 
ally commences at the periphery of the articular cartilage, and from here 
the granulations dip down into the vascular bone, and often undermines 
the cartilage extensively before any destructive changes are witnessed on 
the side directed toward the joint. In such cases the cartilage is not only 
often extensively detached, but perforated at numerous points by the granu- 
lations underneath it. The action of the granulations on the articular ex- 
tremities of the bone produces a condition which has been described for 
centuries as caries. Caries is not a disease, but the result of a disease. The 
bone is softened, and by molecular disintegration, caused by action of the 
granulations, it becomes porous and honey-combed. Numerous miliary 




Fig. 193. — Tubercular Empyema of Knee-joint. 

nodules, can be seen in the affected area, which, in the course of time, un- 
dergo coagulation-necrosis and caseation. In long-standing cases the de- 
struction of bone is so extensive that in the hip-joint, for instance, it may 
result in the loss of the entire head of the femur and perforation of the 
acetabulum. 

Symptoms and Diagnosis. — The symptoms vary according to the type 
of the disease and manner of infection. "With the exception of circumscribed 
points of tenderness outside of the region of the joint that indicate the ex- 
istence of primary osteotuberculosis, we have no symptoms which enable us 
to make a positive diagnosis between a primary osteal and a primary synovial 
tuberculosis of a joint. The primary osteal form is the most common. In 
the knee the proportion of the primary osteal to the primary synovial form 




a ^ 

o - 
"T 2. 

ft 3 

■£ -° 

M) ^ 
(5 ^ 



IUBBBC1 LOBIS OF JOINTS. 575 

is in the proportion of 8 to 1; in the hip, 4 to 1; in the elbow, 4 to 1. As 
to age, the proportion is, in children below 15 years of age, 2 to 1; above 
15, 3 to 1. In reference to the location of the joints affected, it can be said 
that joint tuberculosis is much more frequent in the lower than in the upper 
extremities. According to Albrecht, out of 325 cases, in 91 the disease 
affected the joints of the upper and in 23-1 those of the lower extremities. 
1. Swelling. — In the atrophic form of plastic synovitis — the caries 
sicca of Volkmann, so common in the shoulder-joint — there is not only no 
swelling, but the region of the joint may even be found atrophied from mus- 
cular atrophy. The absence of swelling and the presence of considerable 
mobility in the joint may lead to a wrong diagnosis under the impression 
that the affection is a neurosis. A careful examination under the influence 
of an anaesthetic will, however, reveal restriction of mobility from cicatricial 
contraction of the tubercular capsule, which will enable the surgeon to make 
an early and correct diagnosis. The swelling resulting from tubercular hy- 
drops and abscess is caused exclusively by distension of the capsule with fluid, 
as the capsule in either case is but little thickened and the granulations are 
scanty. In both of these conditions the capsule of the joint is often enor- 
mously distended. In the knee-joint the patella is raised from the condyles 
of the femur, and the depression on each side of it, present in a normal con- 
dition in the extended position of the limb, is not only effaced, but replaced 
by a well-marked prominence. Fluctuation is distinct. In the dry, fungous 
variety of synovitis the swelling is due to the masses of granulation-tissue 
within, and, after perforation of the capsule has occurred, within and outside 
of the joint. This is the most common of all the forms of articular tuber- 
culosis. The old authors were of the opinion that the oedema in the neigh- 
borhood of a white swelling was due to expansion or enlargement of the 
articular extremities of the bones, until Samuel Cooper pointed out that it 
was caused by thickening of the capsule. The granulation-tissue is often 
present in such abundance as to give rise to considerable distension of the 
joint, and, in the knee-joint, elevating the patella from the condyles of the 
femur to such an extent that the contour of the joint simulates an effusion 
into that articulation. The granulations are so soft that on palpation in 
these cases fluctuation can be distinctly felt, especially if the. capsule of the 
joint is very thin from overdistension or destructive changes. To ascertain 
the character of the contents of such a joint it is usually necessary to resort 
to an exploratory puncture. The invasion cf the paraarticular tissues causes 
considerable swelling in the region of the joint, imparting to the latter the 
characteristic spindle shape so frequently found in the knee-, elbow-, and 
ankle- joints, the swelling being so much the more conspicuous when atrophy 
of the muscles aboye and below has taken place. Extension of the infiltra- 
tion from the paraarticular tissues in the direction of the subcutaneous tis- 



576 



PRINCIPLES OF SURGERY. 



sues finally causes the swollen joint to be covered with a whitish, immovable, 
dense skin, giving the joint the appearance from which the time-honored 
name of white swelling was derived. If a periarticular abscess appear the 
swelling of the joint is generally diminished, while a new swelling forms in 
the vicinity or some distance from the joint. 

2. Pain. — Pain, as a symptom accompanying tuberculosis of joints, al- 
though always present, is of extremely variable intensity. In some cases it 
is so slight that patients will continue to use joints distended with masses 
of fungous granulations without much suffering, while in other instances 
a limited disease in the joint will cause complete disability and a great deal 






Fig. 195. 



-Knee-joints. A, normal knee-joint; B, tubercular hydrops; 
osteomyelitis of internal condyle of femur. (Albert.) 



C, tubercular 



of suffering. According to my observation, the pain is usually more severe 
in cases where the granulations are scanty than when the synovial mem- 
brane is the seat of extensive fungosities. As a point in differential diag- 
nosis, it may be said that in osteal tuberculosis pain is present from the be- 
ginning in the bone, and is not much aggravated by the joint disease; while 
an almost painless primary synovial tuberculosis is followed by severe pain 
with nocturnal exacerbations as soon as the synovial membrane and articu- 
lar cartilage have been destroyed and the bone has been secondarily impli- 
cated in the inflammatory process. Absence of tenderness away from the 
joint and its presence in the line of the joint would indicate rather a pri- 
mary synovial tuberculosis than the osteal variety. In primary synovial 




Fig. 196. 



-Dry Tuberculosis of the Shoulder-joint (Caries Sicca), showing Extensive 
Destruction of the Head of the Humerus. 



TUBEfiCULOSIS OF JOIfl PS, 577 

tuberculosis in the hip-joinl the pain is located in the joint and the groin; 

while in the osteal form, during the early Btage at least, it is usually referred 
to the inner aspect ol' the knee. 

3. Deformity. — Contraction, lateral deviations, subluxations, and other 
abnormal positions usually indicate more or less destruction of the articular 
surfaces of the bones and ligaments. These malpositions are not seen in 
articular tubercular hydrops or the milder forms of synovial tuberculosis, 
while we find different degrees of one or more of them nearly in every case 
of advanced fungous synovitis. Watson Cheyne has again called attention 
to the fact that, in chronic inflammation of joints, the explanation of Bonnet, 
that contractions are caused by intraarticular pressure, is no longer tenable, 
as Luecke (Deutsche Zeitschrift fur CMrurgie, B. xxi, H. 5) has shown con- 
clusively that in fungous disease of joints the flexed position is induced by 
the irritation due to the inflammation, as in that posture the least amount 
of pain is incurred. If the patient now attempt to walk he naturally contracts 
all the muscles so as to avoid any movement which would aggravate the pain. 
This contracted state of the muscles, however, tends still to heighten the 
degree of flexion, as the flexors are naturally and anatomically stronger and 
less easily fatigued than the extensors. Therefore, the longer this flexed 
position has been maintained, the more marked it becomes, as is the case in 
paralysis originating in the nervous centres. Luecke is of the opinion that 
in chronic joint-disease the posture of the joint is adopted voluntarily or 
from expediency so as to facilitate the use of the limb in the same manner 
as scoliolordosis is adapted to compensate adduction, disappearing when the 
patient is confined to bed, as its only purpose is the avoidance of limping. 
The posture is further influenced by the destruction of integral parts of the 
joints; adduction in the hip- joint, for instance, is caused by destruction of 
the acetabulum, as the varus position of the knee is due to destructive 
changes affecting the internal condyle of the femur or the inner tuberosity 
of the tibia. In advanced cases of synovial tuberculosis of the knee-joint 
the joint is flexed, the leg rotated outward, and the head of the tibia dis- 
placed backward. In the hip-joint the disease gives rise to flexion of the 
thigh upon the pelvis, and first eversion, but later inversion, of the limb. 
After separation of the head of the femur, or extensive destruction of the 
articular end of this bone and the acetabulum, the contour of the region of 
the hip-joint and the position of the limb simulate dislocation of the head 
of the femur upon the dorsum of the ilium. Tubercular disease of the elbow- 
joint gives rise to flexion and pronation of the forearm. The clinical im- 
portance of any of these displacements lies in the fact that they signify a 
certain amount of destruction of the joint-structures, thus often indicating 
surgical interference for the correction of the deformity, as well as the re- 
moval of the diseased tissue. Eemembering the frequency of tubercular 



578 PRINCIPLES OF SURGERY. 

affections of joints, as a rule, there is little difficulty in their recognition, if 
the historv. course, and symptoms are carefully studied and analyzed. Konig 
justly remarks that it is well to remember that articular tuberculosis, even 
if the disease affect a large joint, is practically a local disease, and has for 
a long time little or no influence on the general health of the patient. Thus, 
we may find patients presenting all the appearances of robust health suffer- 
ing from articular tuberculosis. The tubercular articular hydrops is distin- 
guished from a catarrhal or rheumatic synovitis with copious effusion by its 
persistency and tendency to return after aspiration or after active use of the 
joint. The presence of flocculi or rice-bodies in a joint confirm the tuber- 
cular nature of the affection. A tuberous synovitis, with the formation of a 
single mass of fibrous tissue, sessile or pedunculated, might be mistaken for 
lipoma arborescens or gummata. The diagnosis of the latter will be cleared 
up by a course of antisyphilitic treatment, which should always 'be instituted 
in cases of doubt. Tubercular joint-abscess is distinguished from suppu- 
rative, gonorrhoea!, or rheumatic synovitis by the pain being less and the 
absence of all signs of acute inflammation. The local conditions in fungous 
synovitis are so characteristic that they can hardly be misinterpreted by a 
careful observer. The presence or absence of fluid in the joint has often to 
be determined by an exploratory puncture. The caries sicca of Volkmann, 
or dry, pannous, hyperplastic synovitis of Hueter, especially as found in the 
shoulder-joint, might be mistaken for a neurosis, with atrophy of the mus- 
cles covering the joint. The differential diagnosis cannot be made without 
the examination while the patient is fully under the influence of an anaes- 
thetic. If the affection is a neurosis, motion will be found unimpaired: if it 
is tubercular, the mobility of the joint will be found lessened by intraarticu- 
lar adhesions and cicatricial contraction of the capsule of the joint. 

Prognosis. — Tuberculosis of a joint may terminate in a spontaneous 
cure in cases in which the intensity of the infection is slight or the re- 
sistance on the part of the patient is so great that the fungous granula- 
tions do not undergo degenerative changes, but are converted into con- 
nective tissue. A partial or complete synechia of the cavity of a joint is 
often one of the unavoidable results in such cases, leaving the joint in a 
permanently stiff condition. This endeavor on the part of the organism 
to limit the extension of the disease is often observed in cases in which the 
joint affection occurs in connection with osteal tuberculosis. As soon as per- 
foration of a focus into a joint has occurred a wall of granulation-tissue 
is thrown out around the circumscribed area of infection, and, under 
favorable circumstances, a partition of cicatricial tissue is formed which 
isolates the infected from the intact portion of the joint. In such in- 
stances we have an illustration how the tubercular process is retarded, 
and sometimes permanently arrested, by the transformation of granula- 




Fig. 



197.— Pathological Subluxation of the Hip-joint following Extensive Destruction 
of the Head of the Femur by Tubercular Cavities. 



CUBEECTJLOSIS OF JOINTS. 579 

t ion- into connective tissue. For such a favorable termination to take 
place it is accessary that the tubercular virus should be attenuated by age 
or want of a proper nutrient medium, or that the pathogenic effect of the 
bacilli should be neutralized by an adequate resistance on the part of the 
tissues beiore degenerative changes have occurred in the granulation- 
tissue. The course of articular tuberculosis is so variable in different cases 
that it is impossible, during the early stages of an attack, to predict any- 
thing certain in reference to the probable outcome. A spontaneous cure 
is more likely to take place if the patient is young, not anaemic, and, at 
the same time, well nourished. The hygienic surroundings must also be 
taken into consideration in rendering a prognosis. The disease shows 
greater tendencies to limitation in children than in persons past the age 
of puberty. 

Among the different forms of joint tuberculosis the tubercular 
hydrops and caries sicca are the most benign, and in these cases a spon- 
taneous cure is most frequently realized and the same conditions are also 
most amenable to successful surgical treatment. The caries sicca may, 
according to Konig, terminate in a spontaneous cure in two or three years, 
with some loss of motion in the joint. It is sometimes difficult to ascer- 
tain in a given case when the lesion can be considered as cured. As the 
most reliable evidences that such favorable termination has taken place 
must be considered disappearance of swelling, pain, tenderness, and 
restoration of function as far as this can be expected. The patient should 
not be permitted to use the limb until the active symptoms of inflamma- 
tion have disappeared. The danger to life arises from the existence of 
complications, foremost among them being septic infection, pulmonary or 
general tuberculosis, and amyloid degeneration of important internal or- 
gans. Septic infection is caused either by localization of pus-microbes 
brought to the tubercular focus through the circulating blood, or, what 
is more frequently the case, through an infection-atrium, created by a 
spontaneous opening; through an operation wound; an exploratory 
puncture; or, finally, through a fistulous communication with the joint. 
Many neglected cases of joint tuberculosis die annually of pulmonary or 
general tuberculosis. Billroth states that in sixteen years 27 per cent, of 
bone and joint tuberculosis were lost in this way. Kbnig, from a table of 
117 operations for tuberculosis, found that after four years 16 per cent. 
had died from general tuberculosis. If a patient escape death from septic 
infection after secondary infection with pus-microbes, he is liable to suc- 
cumb several years later to amyloid degeneration of the spleen, the liver, 
and especially the kidneys, with its accompanying anasarca. 

Treatment. — As spontaneous cure in cases of joint tuberculosis is 
more frequently the exception than the rule, and if, finally, it does take 



580 PRINCIPLES OF SURGERY. 

place it does so generally after the limb has become so much deformed 
that it is useless and will require a formidable operation to restore partial 
function, it is evident that timely surgical treatment should be adopted to 
eradicate the disease, preserve function, and, at the same time, protect the 
patient as far as can be done against general infection. 

1. Rest. — As in cases of osteotuberculosis, rest is an important ele- 
ment in the treatment of tubercular joints. It is even more important to 
secure rest for an inflamed joint than for an inflamed bone, as the inflam- 
mation is always greatly aggravated by the movements in the joint that 
necessarily take place as long as the joint is used, which does not apply 
with equal force to cases of osteotuberculosis. During the early stage of 
hip-joint tuberculosis rest in bed and extension by weight and pulley are 
best calculated to secure rest for the diseased joint and to guard against 
deformity. After the acute symptoms have subsided the patient should 
avail himself of the benefits to be derived from out-door air and exercise 
by the use of crutches and Hutchinson's shoe or Sayre's extension-splint. 
The best method to procure rest by treatment in ambulando is to im- 
mobilize the limb in a plaster-of-Paris splint, which does not necessarily 
confine the patient to his room or bed. If one of the lower extremities is 
to be incased in a plaster splint, I am in the habit of applying the plaster- 
of-Paris roller over tight-fitting, knit drawers, which protect the skin 
much better than an ordinary roller bandage. All bony prominences 
should be protected against pressure by careful padding with absorbent 
cotton. If the hip-joint is the seat of inflammation the splint is applied 
with the limb in the extended position, while the patient stands on the 
sound limb upon a low stool, as in this position autoextension is made by 
the weight of the suspended limb. In such cases the splint must extend 
from the toes and embrace the entire limb, the whole pelvis, and abdo- 
men as far as the umbilicus, and the opposite limb as far as the knee-joint. 
In tuberculosis of the knee-joint the splint should extend from the toes 
to the groin, and. in ankle-joint affections, from the toes to the knee-joint. 
Immobilization is to be made with the limb in such a position that in case 
the joint should become permanently stiff the limb can be used to great- 
est advantage. A slight degree of flexion in the hip- and knee- joints is to 
be preferred to a perfectly straight position. In inflammation of the 
shoulder-joint the limb makes the necessary counter-extension, and fix- 
ation of the joint is secured by confining the limb, with the forearm flexed, 
at right angles to the side of the chest, by strips of adhesive plaster or a 
plaster-of-Paris bandage. The hand should be slightly extended in im- 
mobilizing the forearm in the treatment of tuberculosis of the wrist, while 
the forearm is flexed at a right angle to the arm in tubercular synovitis of 
the elbow-joint, with the hand in position half-way between pronation and 



rUBERl I LOSIS OF JOINTS. 58 I 

supination. Early immobilization <>f a tubercular joint not only secures 
absolute rest for the joint, but, at the Bame time, this treatment prevents, 
to a greal extent, subsequent deformities. Treatment by immobilization 
should be continued until all symptoms of inflammation have subsided, or 
until more radical measures become necessary. If the arthritis has al- 
ready resulted in contractures the treatment by extension with weight 
and pulley is in place, and should be continued until the limb has been 
brought in proper position for treatment by immobilization. 

2. Aspiration. — In tubercular hydrops the intraarticular effusion is 
often very copious, resulting in enormous distension of the capsule of the 
joint, which, if continued for any length of time, must necessarily result 
in great weakening of the joint. Aspiration under these circumstances 
relieves the distension and places the vessels in the synovial membrane in 
a better condition to perform their function in the subsequent removal of 
the inflammatory product by absorption. After evacuation of the con- 
tents of the joint the limb should be immobilized and rapid reaccumula- 
tion of the fluid prevented by uniform, equable compression of the joint 
by strips of adhesive plaster or rubber bandage. 

3. Tapping and Iodoformization. — In tubercular hydrops and abscess 
of a joint subcutaneous evacuation of the fluid contents, followed by iodo- 
formization practiced in the same manner as has been described in the 
treatment of tubercular abscess, yields more satisfactory results than 
simple aspiration. In tubercular hydrops irrigation of the joint with a 
3-per-cent. solution of boric acid is only necessary for the removal of rice- 
bodies; if such are not present, the iodoform mixture may be injected at 
once. Krause, during a period of eighteen months, treated 43 tubercular 
joints by means of iodoform injections; cases were treated by other means, 
and where cure without operation seemed impossible, but in which fistulas 
were not yet formed. The injections were repeated at intervals of two or 
three weeks. Pain was greatly relieved by this treatment; the swelling 
yielded much more slowly, though in six weeks some cases showed a reduc- 
tion in size and a hardness of the affected parts. The abscess-cavities fre- 
quently filled again, rapidly at first, but ultimately reaccumulation ceased. 
In some cases fistulas formed at the seat of puncture, which first discharged 
pus, then serum, but ultimately healed entirely. In a fair percentage 
treated in this way definitive healing was obtained. This treatment 
promises the best results in cases where granulation-tissue is scanty, and 
where the inflammatory product has not undergone extensive caseation. 
This treatment of tubercular joints has had a very extensive trial in the 
clinic of Rush Medical College, where, during the last ten years, hundreds 
of patients have reaped its benefits. In well-selected cases I know of no 
treatment which is equal to it. Iodoform has a decided antibacillary effect 



582 PRINCIPLES OF SURGERY. 

in uncomplicated tuberculosis of joints; it is useless after the tubercular 
process has become the seat of infection with pyogenic microbes. Bill- 
roth opens the joint, evacuates its contents through the incision, removes 
(if present) tubercular sequestra, rice-bodies, and tubercular membranes, 
and then treats the joint by iodoformization. In general practice, how- 
ever, it is much safer to follow the subcutaneous method by puncturing 
the joint with a medium-sized trocar, using the cannula for evacuation, 
irrigation, and iodoformization. Hahn has obtained very satisfactory re- 
sults by the substitution of formalin for iodoform in the treatment of 
tubercular arthritis, tubercular abscesses, and tubercular empyema. He 
uses 1 to 10 parts of a 35-per-cent. solution of formalin in 100 parts of 
glycerin, as an injection after the abscess has been evacuated and washed 
out with boric-acid solution. A. M. Pheljis incises the joint freely, fills it 
with pure carbolic acid, which is allowed to remain for a few minutes, when 
it is washed out with pure alcohol: lastly, the joint is irrigated with a weak 
solution of alcohol, a glass drain is inserted, and the usual absorbent aseptic 
dressing is applied. 

4. Arthrectomy. — Excision of the infected tissues in primary tuber- 
culosis of the synovial membrane has been practiced for a number of 
years, and the results of this treatment have been quite encouraging. 
Primary synovial tuberculosis, without any foci in the articular ends of 
the bones and which resists the treatment by tapping and intraarticular 
iodoformization, should be treated by arthrectomy, and not by resection, 
as by the former operation the diseased tissues can be removed effectually 
without unnecessary loss of healthy tissues that are sacrificed by the latter 
operation. The success of an operation for tubercular affections depends 
largely upon the thoroughness with which the operation is done and the 
absence of suppuration. Arthrectomy should be performed before fistu- 
lous openings have formed, and the joint must be opened by an incision 
that will expose every nook and corner of the capsule. Of the many in- 
cisions that have been devised for opening the knee-joint, the one I shall 
describe here offers the greatest advantages and is open to the least ob- 
jections. The old-fashioned horseshoe incision, with the convexity 
directed downward, makes it very difficult to suture the wound, and leaves 
a scar where it is most exposed to injury. The incision carried directly 
across the knee-joint, if the patella is divided at the same time, leaves, 
subsequently, the superficial and deep parts of the wound directly oppo- 
site; if the patella is preserved, the scar of the external incision falls 
upon the most prominent part of the patella, which is again a great dis- 
advantage. The incision which for several years I have always selected 
in opening the knee-joint in performing arthrectomy or resection is 
Halm's incision, which is slightly curved, but with the convexity directed 



TUBERCULOSIS OF JOINTS. 583 

upward. It is carried from the most dependent portion of the knee-joint, 
at a point corresponding to the most prominent part of the internal 
condyle o( the femur, in a gentle curve to an inch above the upper border 
of the patella, and from here downward and outward to a point opposite 
where it was commenced. The short, semilunar, cutaneous flap is now 
detached and turned downward. After this an incision is carried directly 
across the joint, dividing the lateral ligaments and crossing the patella 
transversely at its centre. The patella, at this step of the operation, is 
divided with a saw. The upper recesses of the synovial sac are freely 
opened by making an incision on each side of the upper half of the 
patella, which is carried as far as the upper recess of the synovial sac. The 
rectangular flap, composed of the upper end of the patella with its muscu- 
lar attachments, is reflected, which exposes every portion of the upper 
part of the synovial recess. A somewhat similar flap is made of the 




Fig. 198.— Hahn's Incision for Arthrectomy, or Resection of the Knee-joint. 

lower half of the patella and its tendon, reflected in a downward direction, 
by which the tissues underneath that portion of the patella and its liga- 
ment are fully exposed. With the knee-joint thus exposed it is not diffi- 
cult to extirpate, with the help of a catch-forceps, a sharp scalpel, and a 
pair of curved scissors, the entire capsule. The part of the capsule that 
will be found most difficult to remove is that portion which covers the 
popliteal vessels and dips down behind the condyles of the femur and be- 
hind the tuberosities of the tibia. During this part of the operation the 
leg must be forcibly flexed over a small cushion, or the fist of an assistant, 
in the popliteal space. Arthrectomy is always a tedious operation, as it is 
absolutely necessary to remove all of the infected tissues in order to secure 
permanent success. If the patella is not diseased it should never be re- 
moved. After the capsule has been extirpated the patella is united by 
two chromicized catgut sutures. I have never failed in obtaining bony 
union in four to six weeks after this method of coaptation. After ex- 



584 PRINCIPLES OF SURGERY. 

tirpation of the capsule, and before the elastic constrictor is removed, the 
whole surface should be once more irrigated with a hot, aqueous solution 
of iodine or salt solution, after which it is rubbed off with dry iodoform 
gauze, in order to remove any detached fragments that have not been 
washed away. The whole surface is now freely sprinkled with impalpable 
iodoform, which is rubbed into the surface. Before the constrictor is 
removed the wound is packed with aseptic gauze, the flaps are laid over it, 
and manual compression made for five to ten minutes after the removal 
of the constrictor, with the limb in an elevated position. This simple 
procedure serves an admirable purpose in controlling capillary haemor- 
rhage, and reduces the necessity of recourse to ligature to a minimum. 

After all the bleeding has been arrested the patella is sutured, and 
the deep parts of the wound are united by buried sutures. Tubular drain- 
age can usually be dispensed with, as a capillary drain composed of a few 
threads of catgut will answer an excellent purpose, and will not, like the 
tubular drain, necessitate an early change of dressing. The external in- 
cision is closed with silk-worm-gut sutures, the line of suturing being out 
of the way of the patella, the parts united with the buried sutures being 
covered throughout by the external flap. A careful hsemostasis and rigid 
antiseptic precautions will make it unnecessary to change the dressing 
earlier than the end of the second week, and on this account I prefer to 
immobilize the limb in a bracketed plaster-of-Paris splint, or a plastic 
posterior splint, applied over a copious antiseptic dressing. The limb must 
be kept in an elevated position for at least six hours after the operation, 
so as to diminish the amount of parenchymatous haemorrhage. If all the 
infected tissues have been removed and the wound remain in an aseptic 
condition, the external wound will be found closed in the course of two 
or three weeks. A fair restoration of function with partial mobility of the 
joint can be expected in favorable cases. Passive motion must be delayed 
until the patella has firmly united, which will require from three to four 
weeks in children and nearly twice this length of time in adults. After 
the patella has united and the external wound is completely healed, re- 
covery is hastened by passive motion, massage, and use of the faradic cur- 
rent. Arthrectomy has a promising future in the treatment of primary 
synovial tuberculosis of the knee-joint, but for well-known anatomical 
reasons it is not equally applicable in the treatment of synovial tubercu- 
losis of any other of the larger joints. It is possible that the operation 
will be modified and sufficiently perfected in the future so as to be more 
applicable in the treatment of synovial tuberculosis of the hip- and 
shoulder- joints. In a number of cases of tuberculosis of the elbow-joint 
I obtained an excellent result from arthrectomy combined with temporary 
resection of the olecranon process. This process was divided obliquely 



TUBERCULOSIS OF JOINTS. 585 

with a saw at its junction with the Bhafl of fche ulna, ami, after the extir- 
pation of all of the infected soft tissues of the joint, the process was 
fastened in its proper place with an aseptic ivory nail or chromicized cat- 
gut sutures. The functional result was satisfactory. 

5. Atypical Resection. — The incision (superficial and deep) in atypical 
and typical resection of the knee-joint should be the same as has been de- 
scribed above. The patella is divided transversely, and if it does not contain 
a tubercular focus it is not necessary or advisable to remove it, as its con- 
tinuity after resection can be restored by suturing with a durable form of cat- 
gut. An atypical resection consists in the removal of tubercular foci in the 
epiphyseal extremities of the bones that enter into the formation of the joint, 
without removing the entire articular extremities by a transverse section 
with the saw. The unnecessary removal of the epiphyseal extremities 
should especially be avoided in the case of children, as the removal of one 
or both centres of growth of bone will result in so much shortening of the 




Fig. 199. — Interrupted Plaster-of-Paris Splint for Resection of the Knee-joint. 

limb subsequently as often to render it not only perfectly useless, but 
it becomes a burdensome appendage. In children atypical resection should 
be practiced in all cases where all the foci in the articular extremities can 
be reached and removed by this method. The proper instruments to be 
used in this operation are the chisel, bone-forceps, and sharp spoon. After 
the joint has been freely opened, the articular surfaces are carefully in- 
spected for evidences of deep-seated foci. If perforation into the joint has 
taken place the cavity is freely exposed from the articular surface, and 
all of the infected tissues are removed with chisel and sharp spoon. It 
is important not only to remove necrosed bone, granulation-tissue, and 
caseous material, but also the surrounding osteoporotic zone of bone that 
possibly might contain tubercle bacilli. A deep-seated focus may be sus- 
pected and should be searched for if the articular cartilage has become 
detached over a greater or less extent. Explorations with a small per- 
forator can be made in different directions from the articular surface in 



586 PRINCIPLES OF SURGERY. 

searching for deep-seated foci. If the articular cartilage has become de- 
tached over a considerable area by granulations underneath it, it should 
be removed, and the exposed bone must be subjected to another careful 
examination for the purpose of locating and treating deep-seated foci. A 
circumscribed area of great vascularity is a suspicious indication and calls 
for a limited excavation with a small, sharp spoon for diagnostic purposes. 
It is well for the surgeon to remember that primary osteotuberculosis 
with secondary involvement of a joint usually consists of more than one 
focus in one or both epiphyseal extremities. A tubercular infarct is gen- 
erally recognized by examining the articular surface, as the cartilage or 
the exposed portion of the wedge-shaped sequestrum presents appearances 
of necrosis that cannot be mistaken. After the extraction of the seques- 
trum the tubercular cavity is submitted to the same treatment as when 
dealing with a granulating or caseous focus. In primary synovial tubercu- 
losis, with extension of the disease to the subjacent bone, it becomes 
necessary to remove the honey-combed, softened bone over the entire 
surface with the sharp spoon and chisel. Before the operation is ex- 
tended to the bone in osteotuberculosis it is always necessary first to 
extirpate with knife and scissors the infected soft structures of the joint, 
the synovial membrane, and ligaments, as otherwise the healthy vascular 
bone may become an infection-atrium for traumatic infection, — a not very 
infrequent and serious complication after operations on bones and joints 
for tubercular affections. 

Wartmann, after giving a careful account of the results following ex- 
cision of tubercular joints in the hospital practice of Feurer, gives the 
statistics of 837 cases of excision of joints for tuberculosis from the 
practice of different operators. Of this number 225 died. Of the fatal 
cases, in 26 death followed the operations closely, and resulted from acute 
tuberculosis, probably induced by the operation. Konig observed 16 cases 
in his own practice in which miliary tuberculosis followed almost imme- 
diately after operations on bones and joints for tubercular affections. Konig 
states that the secondary or reinfection sets in seven to ten days after opera- 
tion, which may have been perfectly aseptic, with healing of the wound by 
primary union. The secondary tubercular infection appears either as an 
acute general miliary or pulmonary tuberculosis, or tubercular meningitis, 
terminating in death three or four weeks after the operation. It is not diffi- 
cult to conceive the modus opercmdi of such an occurrence. The resection 
wound opens numerous veins in the bone, the lumina of which remain 
patent, ready for the introduction of minute fragments of granulation-tissue 
or bacilli, which, on entering the venous circulation, are the direct cause 
of metastatic tuberculosis in distant organs. We must take it for granted 
in such cases that a tubercular focus, during the operation, furnished the 



TUBERCULOSIS OF JOINTS. 587 

essential infected fragments of granulation-tissue, or free bacilli are aspi- 
rated or forced into the openings of wounded vessels, and through them 
gain entrance into the general circulation. To guard against such an acci- 
dent it is necessary to remove from the joint all possible sources of infection 
before operating on the articular extremities. Cartilage that remains firmly 
attached to the bone may be left. After all foci have been radically elimi- 
nated, the field of operation is flushed with an antiseptic solution, and, after 
drying and iodoformization, the bone-cavities are packed with antiseptic de- 
calcified bone-chips, and the operation is completed in the same manner as 
in arthrectomy. 

The treatment of bone-cavities with decalcified bone-packing is of the 
greatest utility in atypical resection. An atypical resection with subsequent 
implantation of decalcified bone has for its objects complete removal of the 
infected tissues in the joint and the surrounding bone, and the partial res- 
toration of the parts destroyed by disease or removed during the operation. 
In atypical resection of the knee-joint it is not uncommon that nearly an 
entire condyle of the femur or tuberosity of the tibia must be removed. In 
such cases the surgeon aims at bony union between the articular ends of 
the bones, which is accomplished in the most satisfactory manner by plac- 
ing the parts in a condition to repair the lost bone-tissue, which may be 
done by filling the defect with decalcified bone-chips. I have repeatedly 
made excavations in one of the condyles of the femur and in the head 
of the tibia from the joint surface, the size of a small orange, and ob- 
tained bony ankylosis, with the limb in a good position, by filling the 
cavities with bone-chips. As the bone-chips are always iodoformized be- 
fore implantation, they serve a useful purpose not only by furnishing 
a temporary scaffolding for the reparative material, but they constitute 
a valuable therapeutic measure in the prevention of a local recurrence 
of the disease in case tubercle bacilli should remain in the cavity or 
its immediate vicinity. Immobilization of the limb after resection 
should be continued until the process of repair has been completed, 
which, under the most favorable conditions, requires from six weeks to 
two months. Atypical resections can be made use of in the treatment of 
all joints by resorting to temporary resection of bony prominences which 
are in the way of free access to the cavity of the joint. In atypical resection 
of the hip-joint, for instance, the greater trochanter is temporarily detached, 
which at once exposes the neck of the femur freely, and after dislocation of 
the head of the femur the diseased parts of the joint are exposed for efficient 
direct treatment. The removal of the greater trochanter is seldom neces- 
sary, as it is only exceptionally involved by the tubercular process. After 
the operation is completed the trochanter is sutured in position with strong 
catgut, and this method of direct fixation never fails in securing bony union 



588 PRINCIPLES OF SURGERY. 

if the wound remains aseptic. The elbow- joint is most accessible through a 
long, straight, posterior incision, and after temporary resection of the olec- 
ranon process. Atypical resection of the ankle-joint can be done through 
two lateral incisions, after temporary resection of the malleoli, with chisel 
and sharp spoon. In all resections, atypical and typical, ignipuncture is in- 
dicated after the excision has been completed, if any portion of the bone is 
abnormally osteoporotic, as this procedure will stimulate the process of re- 
pair, and may prove useful in destroying infected tissues, which, from their 
macroscopical appearance, indicate a healthy condition. 

6. Typical Resection. — In typical resection one or both articular ex- 
tremities are sawn across and removed. In the hip-joint it implies the ex- 
cision of the head, neck, and part or the whole of the greater trochanter of 
the femur. A typical resection of the wrist-joint means the removal of the 
entire carpus, with or without the articular surfaces of the radius, ulna, and 
metacarpal bones. In a typical resection of the shoulder-joint the head of 
the humerus is removed. In the knee-joint the operation means excision of 
the articular surfaces of the femur and tibia; in the elbow-joint, of the 
humerus, radius, and ulna; in the ankle, of the tibia, fibula, and astragalus. 
Typical resections are generally made for tubercular affections of the 
shoulder, hip, and wrist-joint. In the remaining large joints it is more fre- 
quently resorted to in adults than children. In children the operation is lim- 
ited, with the exception of the shoulder-, hip-, and wrist- joints, to cases 
where the articular extremities are so extensively diseased that an atypical 
resection would fail in removing all of the infected tissues. Eemoval of the 
diseased synovial membrane and ligaments should precede section of the 
bones with the saw wherever, from the anatomical construction of the joint, 
this can be done. In the hip- and shoulder- joints the head of the bone 
must be removed first before the soft structures of the joint can be extir- 
pated. The operation best adapted for resection of the hip-joint is the one 
by which the trochanter major is preserved. In this operation the section 
of the bone must be made with a chisel. The entire head of the femur and 
as much of the neck as is indicated by the extent of the disease are removed 
by the use of the chisel. The capsular ligament is removed as thoroughly as 
possible, and the acetabulum is scraped out with a sharp spoon. Pro- 
vision for drainage must be made in all hip-joint resections. The after- 
treatment consists of r^st in bed upon a smooth mattress, with the limb ex- 
tended by weight and pulley in an abducted position. This is the usual 
method of fixation of the resected hip-joint. The author has substituted 
for it fixation by means of a fenestrated plaster-of-Paris splint, which, from 
his experience, he regards as a decided improvement, as by it the limb is at 
once placed in a desirable position, in which it is maintained until the heal- 
ing process is completed. After six weeks the patient is allowed to walk on 



TUBERCULOSIS OK JOINTS. -V s !' 

crutches, with a raised sole under the ahoe, worn on the opposite side (Hutch- 
inson's shoe), so thai the limb on the resected side makes the necessary 
autoextension. During the night extension is applied for eight months or 
a year, in order to prevent unnecessary shortening. Eversion and inversion 
of the limb while the patient is in bed are prevented either by a Volkmann 
railway-splint or by supporting the limb with sand-hags, applied to each 
side. Immobilization, after resection of the shoulder-, elbow-, wrist-, knee-, 
and ankle- joints, is best secured in a plaster-of-Paris dressing, which also 
serves an excellent purpose in keeping the antiseptic dressing m situ. 

Temporary resection of the olecranon process in excision of the elbow- 
joint has yielded excellent results in my hands, as by it the insertion of the 
triceps muscle is not disturbed. The resected olecranon, after the removal 
of any foci it may contain, is riveted to the denuded surface of the shaft of 
the ulna with a sterilized ivory or hone nail or chromicized catgut sutures, 
after the resection has "been completed. The forearm is immobilized in a 
semiflexed position until bony union between the shaft of the ulna and 
olecranon process has taken place, which usually requires about six weeks. 
After this time passive motion and massage should he made to increase the 
mobility of the joint. A straight, single incision upon the dorsal side is best 
adapted for resection of the wTist-joint, as the extensor tendons of the hand 
and fingers can be drawn aside sufficiently to afford ample room for the re- 
moval of the entire carpus. In the after-treatment of excision of the wrist 
the forearm and hand as far as the metacarpo-phalangeal joints are incased 
in a plaster-of-Paris splint, with the hand in a slightly-extended position. 
Immediate fixation of the resected ends by means of bone or ivory nails, after 
excision of the knee, is superfluous, as the parts can be kept in accurate 
position by ordinary fixation dressings. In knee-joint resections the section 
through the bones must be made in such a manner that wdien the sawn sur- 
faces are brought in apposition the leg wall be slightly flexed, as this position 
enables the patient to walk more gracefully than with a straight, stiff limb. 
The artificial support must not be removed until firm bony union has taken 
place, which will require from two to three months, according to the pa- 
tient's general health and age. 

7. Amputation. ■ — Amputation must be reserved for cases presenting 
special indications. It is the only operation that promises any benefit if the 
patient suffer at the same time from tuberculosis of other organs, provided 
the general conditions furnish no positive contraindications. It is also in- 
dicated if a tubercular abscess has perforated the capsule of a joint and has 
extensively infiltrated the surrounding tissues. This condition is to be ex- 
pected if the limb has become cedematous some distance from the joint. 
The flaps must be taken from the side of the limb where the skin is in the 
best condition, and the incision through the deeper tissues must be made 



590 PRINCIPLES OF SURGERY. 

through healthy tissue. It is astonishing how rapidly such wounds heal, and 
how quickly patients will recover after amputations for extensive local tuber- 
cular processes, even in patients greatly emaciated by the disease. 



CHAPTER XXIII. 
Tuberculosis of Tendon-sheaths, etc. 

TUBERCULAR TENDO- VAGINITIS. 

Tuberculosis of the tendon-sheaths, or, as Hueter termed this affec- 
tion, tendovaginitis granulosa, has been only quite recently recognized and 
described as a primary local tuberculosis. 

Pathology. — Hueter was of the opinion that this affection is seldom met 
with as a primary lesion, but that it appears usually as a complication of 
joint tuberculosis. As a secondary lesion it is a frequent concomitant of 
osteal and synovial tuberculosis by direct extension of the inflammation from 
the primary focus to tendon-sheaths. Volkmann gave an able and accurate 
description of tendon-sheath tuberculosis in 1875, but at that time he was 
not aware of its tubercular nature. The first scientific treatise on this affec- 
tion came from the clinic at Gottingen by Eiedel, who showed that the rice- 
bodies so commonly found in the so-called fibrinous hydrops of the tendon- 
sheaths, or hygroma of the flexor tendons of the hand, always indicated a 
synovial tuberculosis. Another important paper on the same subject was 
published by Beger, who reports 4 cases that occurred in the clinic at Leipzig. 
The chronic tendo-vaginitis, or compound ganglia of the old authors, has 
been shown to be, on careful clinical observation, microscopical examination, 
and bacteriological research, cases of local tuberculosis. The extension of 
tubercular processes along tendon-sheaths from a tubercular joint after per- 
foration of the capsule has, for a long time, been known to occur, but as a 
primary lesion it has only recently been added to the long list of surgical 
lesions of a tubercular character. As compared with other tubercular affec- 
tions, primary tendon-sheath tuberculosis is quite rare, as it constitutes only 
1 or 2 per cent, of the cases in the statistics of local tubercular lesions. 
"When this affection occurs primarily and independently of tuberculosis of 
an adjacent bone or joint, infection with the bacillus of tuberculosis takes 
place by localization of floating microbes in some small vessel, and subse- 
quently the pathological processes in the tendon-sheaths resemble those of 
tubercular joints. In some cases the products of the disease are ma>-ive 
granulations that occupy the inner surface of the tendon-sheaths; in others 
the granulations are less abundant, but a copious synovial exudation is 
thrown out; while in a third class the granulations form hard, white masses, 
the so-called corpora oryzoidea, which either remain attached to the inner 
surface of the sheath, or, after their separation, are found as loose bodies. 
In the form of tendo-vaginitis which corresponds with the fungous varietv 

(591) 



592 PRINCIPLES OF SURGERY. 

of tubercular synovitis, the granulations form a layer of from 1 to 4 lines 
in thickness upon the inner surface of the sheath. The tendon itself is cov- 
ered with a somewhat thinner layer of granulation-tissue, the granulations 
penetrating the substance of the tendon between the bundles of connective- 
tissue fibres, where, by absorption and pressure atrophy, they cause extensive 
destruction of tissue. In this manner the tendon becomes so much weakened 
that it ruptures on the slightest traction, or, if the disease has progressed still 
further, the loss of continuity becomes complete without a trauma. The 
inrinsic tendency of the disease consists in progressive extension by continu- 
ity of structure along the course of the tendon primarily affected, and when 
this tendon is part of a compound tendon the disease gradually creeps from 
tendon to tendon until all the sheaths are involved. As this affection is met 
with most frequently in the tendon-sheaths surrounding the carpus, and as 
these sheaths are not infrequently in direct communication with the wrist- 
joint by means of small synovial sacs, it extends to the joint by continuity 
of surface. When no such direct connection exists between the tendon- 
sheath and the subjacent joint, the joint may become secondarily involved 
after the granulations have perforated the capsule. Xext to the region of 
the wrist-joint the tendo Achillis, the patellar, and other tendons about the 
knee-joint are most frequently affected. In tuberculosis of the sheaths of 
the tendons of the deep flexors of the ringers the swelling is often large, ex- 
tending from the lower portion of the palm of the hand underneath the 
annular ligament to the middle of the forearm. Underneath the annular 
ligament the swelling is constricted by this structure, which gives rise to con- 
siderable bulging in the palm of the hand and over the lower anterior aspect 
of the forearm (compound ganglion of S} T me). The fluctuating wave can be 
distinctly felt above and below the annular ligament, showing that the two 
swellings are in direct communication. The tubercular product undergoes 
the same pathological regressive changes as in synovial tuberculosis. If a 
sufficient number of tubercle bacilli is present in the granulation-tissue the 
cells are destro} T ed by coagulation-necrosis and caseation, the fungous masses 
breaking down into an amorphous, granular detritus. At this stage perfora- 
tion of the tendon-sheath may take place in an outward direction, and a sub- 
cutaneous tubercular abscess develops. If such abscess open spontaneously, 
or is incised without regard to aseptic precautions, infection with pus-mi- 
crobes will lead to acute suppurative inflammation, which will often result 
disastrously from rapid extension of the phlegmonous inflammation and sep- 
tic infection. The occurrence of rice-bodies in tendon-sheath and synovial 
tuberculosis can be traced to a specific action of the bacillus of tuberculosis 
on the tissues. Konig attributes to this bacillus properties which place it 
among the agents that produce fibrinous inflammation. The rice-bodies in 
the tendon-sheaths, the seat of a chronic inflammation, he considers as the 



rUBBBOULAB TKNDO-VAGI MTIS. 

product of a fibrinous inflammation caused by the action of the bacillus of 
tuberculosis. Nicaise, Poulet. and Yillard examined -i cases of hygroma con- 
taining rice-bodies, and found in all of them the bacillus of tuberculosis. 

Symptoms and Diagnosis. — Tuberculosis of the tendon-sheaths is an ex- 
ceedingly chronic affection. The disease is not painful, and patients often 
continue to follow their occupation after a number of tendons have become 
involved and the swelling has reached considerable dimensions. The swell- 
ing increases in length in the direction of the tendon first affected, and if 
the disease extend to neighboring sheaths it branches out in the direction 
of the tendons affected. In 9 out of 10 cases it attacks a flexor or extensor 
tendon in the region of the wrist-joint, and then extends upward and down- 
ward in the direction of the tendons. In tubercular hydrops of the tendon- 
sheaths the swelling often attains great size. In one such case I found the 
palm of the hand the seat of a swelling, the size of a large orange, that com- 
municated with a smaller swelling above the annular ligament of the wrist- 
joint. In the fungous variety the swelling imparts to the palpating finger 
a semielastic resistance, and fluctuation is either entirely absent or not well 
marked. If rice-bodies are present in considerable number, alternate pressure 
over the lower and upper parts of the swelling produces a distinct sensation of 
crepitation. The disease often extends to the middle of the forearm, and in 
this locality attacks the muscular tissue in the same manner as the tendons 
farther below. Extension to a joint is attended by symptoms that point to 
synovial tuberculosis. The symptoms are so characteristic that a correct 
diagnosis can often be made on first sight. The only affections that must 
be excluded are the ordinary ganglion of tendon-sheaths and acute plastic 
tendo-vaginitis. A ganglion always remains as a circumscribed swelling 
without manifesting any tendencies to extend. The contents of a ganglion 
are a gelatinous mass, of the color and consistence of clarified honey. After 
evacuation of the sac no swelling remains, as the cyst-wall is not much thick- 
ened. A plastic tendo-vaginitis, resulting from injury or overexertion, is 
an acute affection not attended by much effusion or inflammatory exudation. 
The tendon-sheath is abnormally dry, giving rise to friction-sounds which 
can be plainly felt and often heard as the tendon moves within the inflamed 
and roughened sheath. 

Prognosis. — Spontaneous cure is the exception, progressive extension 
the rule. The danger from regional extension arises from the tendencies of 
the disease to invade adjacent joints, and to extend from tendon to tendon, 
and finally along these to the respective muscles. There is no reason why. 
occasionally at least, tendon-sheath tuberculosis should not be followed by 
pulmonary or general tuberculosis in consequence of secondary infection. 

Treatment. — The use of external applications, compression and aspira- 
tion, are of doubtful utility in the treatment of this affection. Tapping, fol- 



594 PKIXCIPLES OP SUKGEEY. 

lowed by iodoformization, promises more, especially in cases of tubercular 
hydrops with few or no rice-bodies. As the rice-bodies contain the essential 
cause of the disease, it will usually be found necessary to remove them in 
order to effect a permanent cure. Eemoval of these bodies, as well as ex- 
tirpation of the granulation-tissue, can only be accomplished by a radical 
operation. A radical operation has for its object the removal of all of the 
infected tissues, which means complete extirpation of the tendon-sheath and 
erasion of the granulations that have invaded the tendon. No operation 
should be undertaken unless the surgeon can count with almost positive cer- 
tainty upon aseptic healing of the wound. Infection with pus-microbes un- 
der such circumstances would not only prevent a satisfactory functional re- 
sult, but would place the patient's life in great peril. Fortunately, this form 
of surgical tuberculosis attacks localities where the surgeon has it in his power 
to obtain, almost with absolute certaint}^, an aseptic healing, of the wound. 
Extirpation of a tubercular tendon-sheath is a tedious and difficult task. The 
operation must be made with the nicety of a dissection in the anatomical 
room. A large tenotomy-knife and a small pair of curved scissors are the 
most useful cutting instruments in making the dissection. A number of 
small tenacula and toothed dissecting-f orceps are necessary to retract tendons 
and expose the parts fully to view. Esmarch's constrictor is an indispenable 
aid, as it renders the tissues perfectly bloodless, which enables the operator 
to identify the parts concerned in the dissection. After the aseptic precau- 
tions have been completed with the greatest care, the limb is rendered blood- 
less and the tendon-sheath is fully exposed by free external incision, which 
should reach on both sides a little beyond the visible limits of the disease. 
The tendon-sheath is now slit open, and the fluid contents are washed away 
by an antiseptic irrigation. 

In operating upon the flexor tendons of the hand and fingers it often 
becomes necessary to divide the annular ligament, which can be done with- 
out fear of impairing the functional result, as, after the operation on the 
tendon has been completed, its continuity can be restored by a number of 
separate buried sutures. The large arteries and nerves are, of course, care- 
fully avoided. In order to remove the tendon-sheath completely, it becomes 
necessary to liberate the tendon and to have it drawn out of the way by an 
assistant. The removal of the deep portion of the sheath requires special 
care, as it often is in close proximity to the underlying joint, which should 
not be opened unless the disease has invaded the capsule deeply. The ex- 
tension of the disease to the muscular tissue can be readily ascertained from 
the naked-eye appearances of the muscle, which, if affected, presents a gray- 
ish appearance, and is firmer than in a normal condition. If the tendon is 
extensively infiltrated its size is often much diminished by the removal of 
the infected portion, which must be done with a sharp tenotomy-knife. If 



TUBEBCULAB TENDO-VAGINITIS. 5#5 

Beveral tendons are affected, and access to the more remote ones is rendered 
impossible without division of the more superficial tendons, these can be 
divided, and again united after the dissection has been completed. I have 

repeatedly spent two hours in an operation for tendon tuberculosis in the 
wrist-joint region, and have always felt that the time was well spent, as a 
hasty operation is often attended by unnecessary injury to contiguous parts, 
and is frequently followed by local recurrence on account of incomplete re- 
moval of the infected tissue. Should it become necessary to resect a portion 
of a tendon on account of extensive disease of this structure, restoration of 
continuity must be effected by an autoplastic operation. The tendon-end 
most suitable for this purpose is selected. The tendon is cut through one- 
half at a distance from its cut end which corresponds with the length of the 
defect, when it is split toward the cut end to within a few lines, and the 
piece is then laid over the defect and sutured at both ends. After the re- 
moval of the infected tissues, the w T ound is irrigated once more with an anti- 
septic solution, dried, and iodoformized. The deep fascia is united separately 
with buried sutures, and the skin is coaptated accurately with interrupted 
stitches and the continued suture. The wound is either sutured throughout 
or a catgut capillary drain is inserted and a copious antiseptic dressing ap- 
plied. The limb is placed upon a well-padded splint with the fingers slightly 
flexed, and, if no indications for a change of dressing arise, the first dress- 
ing is allowed to remain from two to three w T eeks, v\hen the wound will 
be found healed throughout. The functional result is almost ahvays satis- 
factory if the wound heals by primary union. Massage and passive motion 
are instituted as soon as the wound is healed. If the operation is done early 
and with the necessary care, a local recurrence is not to be expected. For 
the purpose of illustrating the pathological conditions and the clinical tend- 
encies of this disease, I will briefly describe one of the many cases of tendon- 
sheath tuberculosis that have come under my observation. This case is re- 
markable on account of the rapid extension of the disease. The patient was 
a -man 60 years of age, laborer, and addicted to intemperate habits. I ex- 
amined him, in consultation with his family physician, about four months 
before the operation w T as performed. At that time I found an oblong swell- 
ing on the dorsum of the right hand, corresponding to the location of the 
extensor tendon of the index finger. The swelling was not painful, and but 
little tender on pressure. Fluctuation was well marked; on deep pressure 
movable bodies could be distinctly felt, which w r ere recognized as corpora 
oryzoidea. An operation was advised, but w T as declined, as the patient was 
still able to follow his occupation. The swelling w r as first noticed six w T eeks 
before the examination, but steadily increased in size. Four months later he 
was admitted into the hospital, as the pain and the size of the swelling now 
disabled him from performing manual labor. At this time the dorsum of 



596 PKINCIPLES OF SURGERY. 

the hand corresponding to the index and middle fingers and the radial as- 
pect of the forearm as far as the middle presented a continuous swelling, 
with well-marked fluctuation. The swelling had lately become painful, and 
was tender on pressure. Under strict aseptic precautions the swelling was 
incised in its entire length, and a large quantity of synovia-like fluid and 
softened rice-bodies escaped. The sheaths of the extensor communis dig- 
itorum and extensors of the wrist were found lined with a thick layer of 
fungous granulations, and near the annular ligament numerous free and 
attached rice-bodies were found. The tendon-sheaths were carefully dis- 
sected out, and the whole wound, after thorough disinfection, was dusted 
with iodoform, drained, and sutured. A copious dressing of iodoform gauze 
and sublimated moss was applied, and the forearm and hand fixed upon an 
anterior splint. Healing of the wound by primary intention. Almost com- 
plete restoration of function. No return after two years, and patient able 
to perform hard manual labor. Inoculations of the fluid upon potato re- 
mained sterile. Cultivation upon coagulated hydrocele-serum showed, after 
a few weeks, a scanty culture of the bacillus of tuberculosis. Implantation 
of one of the rice-bodies into the subcutaneous connective tissue of a guinea- 
pig resulted in a typical tuberculosis, starting from the point of inoculation, 
spreading to adjacent lymphatic glands, and finally resulting, in six weeks, 
in death from diffuse miliary tuberculosis. 

TUBERCULOSIS OF MUSCLES. 

This affection was first described by Zenker in 1870, but in all of the 
cases, 5 in number, published by Oltendorf in 1885, it had extended by con- 
tiguity from an adjacent organ. Similar cases were observed later by G-enz- 
mer, Marchand, Eapp, Bidder, and others. Latour saw a case of tubercular 
abscess of the external radial muscles and of the deltoid, and Denonvilliers 
found an isolated tubercular abscess in the biceps muscle. Habermaas first 
described muscle tuberculosis as a primary affection. Miiller reported a 
similar case from the clinic at Tubingen. The swelling in this case in- 
volved the quadriceps muscle. Delorme gave a description of four cases of 
primary tuberculosis of muscles at the fifth meeting of the Trench Congress 
of Surgeons. J. L. Eeverdin observed a case of primary tuberculosis of the 
triceps muscle. Mendez records 2 cases of tuberculosis of the heart-muscle, 
and refers to 29 cases collected from literature. The first thorough descrip- 
tion of primary muscle tuberculosis was given by Lanz and de Quervain, 
based on the clinical history and microscopical examinations of 8 cases. They 
made careful histological and bacteriological investigations, with a full de- 
scription of the diagnosis, prognosis, and treatment of this affection. The 
results of their observations appear to prove that this form of tuberculosis 
is amenable to successful treatment by thorough excision. 



i LSCLA n BEKOT LOSIS. 597 



FASCIA Tl BERCULOSIS. 

The bacillus of tuberculosis has a special predilection for fascia, and 
primary localization in this tissue is a frequent occurrence. It is a well- 
known clinical fact that, as soon as a deep tubercular focus in a lymphatic 
gland, bones, or joints has reached the connective tissue outside of the organ 
primarily affected, the infection travels along the connective tissue, often 
resulting in quite extensive destruction of this tissue before the process 
reaches the surface. The extension of tubercular abscesses along preformed 
connective-tissue spaces has been previously described. If the tubercular 
product, when it reaches the loose connective tissue, is composed of living 
embryonal tissue, the pathological lesions that are later produced in the con- 
nective tissue correspond with those of the primary lesion. The connective 
tissue is transformed into masses of granulation-tissue, which remain in this 
state for a long time before it is destroyed by coagulation-necrosis, with sub- 
sequent cell-disintegration. In primary tuberculosis of the fascia the dis- 
ease often spreads with great rapidity, dipping down between the muscles 
along the intermuscular septa, and invading from here the muscles them- 
selves. I have seen a number of cases during the last few years where the 
disease originated primarily in the deep fascia of the thigh, resulting in the 
most extensive regional dissemination in the course of two or three years. 
In one case, a veteran of the late war, 55 years of age, the disease commenced 
at a point between the greater trochanter and the crest of the ilium several 
years before he came under my observation. I found the thigh moderately 
swollen with several prominences from the crest of the ilium to the knee- 
joint, where fluctuation was quite distinct. I mistrusted a primary osteo- 
tuberculosis, but, on making free incisions at different points, I found no 
evidence of primary tuberculosis of any other tissue or organ. The deep 
fascia and intermuscular septa were found destroyed, and in their place 
masses of granulation-tissue presenting foci of coagulation-necrosis and 
caseation invading extensively the muscular tissue. Yolkmann's spoon 
was freely used, but I soon found that this treatment was utterly inade- 
quate to remove all the infected tissue, as the deep muscles throughout 
were extensively infiltrated. Amputation was out of the question, as the 
gluteal region as far as the crest of the ilium was so extensively affected 
that it would have been impossible to obtain a covering for a hip-joint am- 
putation. Iodoformization of the enormous spaces made by scraping out 
the fungous granulations had no effect in arresting farther extension of the 
disease. The patient died, three months later, of general miliary tuber- 
culosis. 

In a second somewhat parallel case the disease extended from near the 
knee-joint as far as the trochanter minor. This patient was only 25 years 



598 PRINCIPLES OF SURGERY. 

of age, and the disease had existed a year and a half. Several incisions had 
been made, and a number of fistulous openings were found in communica- 
tions with large cavities between the deep muscles of the thigh. The sinuses 
were laid open and scraped, and the most careful examination failed in dis- 
closing a primary osteal or tendon-sheath tuberculosis. The muscles were 
again found extensively infiltrated and of a grayish-white color, and almost 
of gristly hardness on being incised. The operation rather hastened than 
retarded the progress of the disease, and I was forced, a few weeks later, to 
amputate the thigh just below the trochanters. The patient made a slow 
recovery, but remained in fair health two years after the operation without 
any indications of a local recurrence. I have learned to regard fascia tuber- 
culosis affecting the intermuscular septa of the thigh as an exceedingly 
grave form of local tuberculosis, and, if at all extensive, only amenable to 
successful treatment by amputation. 

TUBERCULOSIS OF MOUTH AND TONGUE. 

We have now every reason to believe that many cases of ulceration of 
the tongue, pharynx, and cavity of the mouth, which have been heretofore 
diagnosticated and treated as carcinoma, were not carcinoma, but syphilis 
or tuberculosis. Professor von Esmarch, in a very able paper, a few years 
ago called attention to the difficulties in the way in differentiating between 
these affections. Out of 114 cases of buccal tuberculosis collected by Dela- 
van, in 1886, only two were on the lip. Mackenzie, of Edinburgh, refers to 
a third; a fourth was seen in Vienna, but not reported; and Welch, of Balti- 
more, had met with a fifth. There can be but little doubt that many similar 
cases have been mistaken for carcinoma. 

Zaudy has studied tuberculosis of the alveolar process. He states that 
the bacilli enter between the gingiva and teeth. Caries acts as a predispos- 
ing cause. The disease is most common in persons between 15 and 50 } r ears 
of age and is more frequent in the male than the female; thus, in 37 cases 23 
were men. 

Pathology. — There is no doubt that many reported cases of permanent 
recovery, after removal by operation of ulcerating swellings of the tongue, 
were not cases of carcinoma, but tuberculosis. Lupus of the phanmx and 
tongue are cases of local tuberculosis. Some time ago I had an opportunity 
to examine a case of primary tuberculosis of the pharynx occurring in a man 
30 years of age. The disease had existed for four months, and involved the 
posterior wall of the pharynx, and had extended to the left tonsil. Bagged, 
deep ulcers had formed, which were covered with flabby, yellowish-gray 
granulations, Numerous minute miliary nodules could be seen in the mu- 
cous membrane around the ulcers, and on scraping away the granulations 
they were also found present in the softened, inflamed tissues underneath the 



il BERC1 LOBIS OF BIOUTH AM) T0NG1 B. 599 

floor of the ulcers. A beginning hoarseness indicated that the disease was 
extending by continuity of tissue to the Larynx. Laryngoscopical examina- 
tion revealed numerous minute nodules, which studded the mucous mem- 
brane of the posterior surface of the epiglottis. The recent advances made 
in the microscopical, bacteriological, and experimental methods of examina- 
tion have succeeded in separating from syphilitic affections and malignant 
disease of the mouth and tongue many cases that belong to the long list of 
affections now classified under the head of surgical tuberculosis. The cavity 
of the mouth is often the seat of slight abrasions and pathological conditions, 
which may become an infection-atrium for the entrance of microorganisms 
that might be contained in the air we breathe, the food we eat, and the water 
we drink. Eemembering the frequency with which superficial abrasions and 
ulcerations occur in this locality, it is not strange that primary tuberculosis 
should occasionally develop here. The tubercle bacillus produces the same 
tissue-changes here as on the surface of the skin, the primary pathological 
product consisting of granulation-tissue undergoing molecular retrograde 
tissue metamorphosis, followed by ulceration. Ulceration is an earlier oc- 
currence and a more conspicuous clinical feature in tuberculosis of the 
mouth than in some other localities, as the new tissue is constantly macerated 
by the fluids with which it is moistened at all times. The tubercular ulcer 
is generally covered by the products of interstitial necrobiosis and superficial 
coagulation-necrosis, which result in the formation of what appears as a false 
membrane. If this membrane, when present, is removed, the characteristic 
granulation-surface is exposed. The ulcer is surrounded by a zone of in- 
flammatory infiltration, which, however, does not present the same feeling of 
hardness as carcinoma. The most characteristic feature of a tubercular ulcer 
of the mouth or tongue consists in the presence of minute tubercle-nodules 
in the margins and underneath the layer of granulations, and, if the infec- 
tion has extended to some distance, in the surrounding mucous membrane. 
Schliferowitsch has published an exhaustive resume of the literature on this 
subject, and has collected all the recorded cases in which the diagnosis of 
tubercular disease of the cavity of the mouth could be made with some degree 
of certainty. The cases number 88, and include those of primary and sec- 
ondary tuberculosis. From a careful study of this affection he has come to 
the conclusion that it occurs seldom in the very young, and that it attacks 
most frequently persons between 40 and 50 years of age. 

Symptoms and Diagnosis. — Tuberculosis of the mucous membrane of 
the cavity of the mouth appears as a flattened, submucous infiltration com- 
posed of granulation-tissue, which, at an early date, becomes the seat of a 
superficial ulceration in the centre that rapidly extends toward the margins 
of the swelling. Caseation is seldom observed. The cells are destroyed by 
coagulation-necrosis, and as they become detached the defect increases in 



600 PRINCIPLES OF SURGERY. 

size. The appearance of the ulcer in this locality is characteristic. If on 
the tongue, it is found on the borders near the tip of the organ. It appears 
as an oblong ulcer, with raised, ragged borders of firmer consistence, show- 
ing the color of fresh granulations. The ulcer often appears as if covered by 
a pseudomembrane; if this covering is removed the surface left easily bleeds. 
The surface of the ulcer is uneven, as if covered with hypertrophic papilla?. 
The discharge of pus is slight, and, in many cases, miliary nodules may be 
found around the ulcer. Pain is not as severe as in carcinoma. Lymphatic 
glands may become secondarily infected, but this is not often the case. In 
the primary form of the disease, when a positive diagnosis is most difficult, 
the presence of tubercle bacilli will demonstrate the nature of the ulcer. A 
gumma of the tongue, as a rule, develops into a larger swelling than a tuber- 
cular affection before ulceration takes place, and the resulting ulcer is more 
deeply excavated; at the same time, other evidences of syphilis can usually 
be detected. Miliary nodules in the immediate vicinity of the ulcer are 
absent in a syphilitic ulcer, and frequently present in tuberculosis. If any 
doubt remain as to the differential diagnosis between these two affections, 
this should be set aside by a course of antisyphilitic treatment before resort- 
ing to any serious operation. If the ulcer is syphilitic it will heal kindly 
under such treatment, while no improvement will be noticeable if it is tuber- 
cular. Epithelioma commences as a superficial infiltration and penetrates 
the tissues from without inward. Induration around and underneath the 
ulcer is more marked in an ulcerating epithelioma than in a tubercular ulcer. 
Glandular infection takes place early, and is almost a constant occurrence in 
epithelioma, but is seldom observed in the course of a tubercular ulcer. In 
a case of primary tuberculosis of the tonsils that recently came under the ob- 
servation of the writer the deep glands of the neck were extensively involved, 
and an examination of the tonsils after their removal showed that they were 
the seat of early and extensive caseation. A simple ulcer of the tongue 
caused by the mechanical irritation from a sharp projection of a carious or 
displaced tooth can be readily recognized by the location and character of the 
ulcer. Such an ulcer may become the seat of a tubercular ulcer or the start- 
ing-point of an epithelioma. 

Treatment. — The local treatment of a tubercular ulcer of the mouth or 
tongue is the same as when a similar ulcer is located upon the surface of the 
body. If the lesion is circumscribed sufficiently that the wound, after com- 
plete excision, can be closed by suturing, this method of treatment should 
be adopted, as it is certainly the most radical, and results most speedily in 
complete recovery. If the extent of the disease render this treatment in- 
applicable, the diseased tissues should be removed as thoroughly as possible 
by a vigorous use of the sharp spoon, or by destroying it with the actual 
cautery, or both of these measures may be combined. The use of superficial 



DUBEKOULOSIS OF THE [NTESTINES. G01 

caustics has a tendency rather to aggravate the disease than to cure it. With 
a sharp spoon all of the soft i issues are scraped away, the healthy tissue being 
recognized by its greatei firmness and resistance to the spoon. After bleed- 
ing has ceased the surface is cauterized with the flat point of a Paquelin cau- 
tery, and, if the disease has dipped in farther at certain points, these are 
attacked by making ignipuncture with the needle-point of the Paquelin cau- 
tery. The cavity of the mouth, during the after-treatment, must be kept as 
nearly as possible in an aseptic condition by dusting the surface daily with 
iodoform, and by the frequent use of a mild, antiseptic mouth-wash, such as 
a saturated solution of acetate of aluminum or boric acid. If all the infected 
tissues have been destroyed, healing takes place rapidly by granulation, cica- 
trization, and epidermization after separation of the eschar. If any of the 
infected tissues have remained, the process of healing is retarded or com- 
pletely arrested; in the latter event a repetition of the same local treatment 
will become necessary. 

TUBERCULOSIS OF THE STOMACH. 

There is reason to believe that tuberculosis of the mucous membrane 
of the healthy stomach does not occur. Tubercular infection of the stomach, 
however, can occur if the mucous membrane and the secretions are so altered 
that the resistance to the tubercle bacillus is lost. Very few well-authen- 
ticated cases of tuberculosis of the stomach have been reported. Orlandi 
records a case of primary tuberculosis of the stomach in a man 20 years of 
age. Of 18 cases so far reported, 14 were males, and among this number in 6 
the ulcers were on the lesser curvature, 4 near the pyloric end, and in 4 
widely distributed over the surface of the mucous membrane. Of 24 cases, 
isolated ulcers were found in 12 and in the remaining 12 the ulcers were 
multiple. 

TUBERCULOSIS OF THE INTESTINES. 

Primary tuberculosis of the intestinal mucous membrane is a compara- 
tively frequent affection, but becomes a surgical lesion only in case it leads 
to intestinal obstruction or perforation. If, as is sometimes the case, the 
infection is limited to a single focus, a timely operation not only relieves the 
symptoms which made surgical treatment a necessity, but it may result in 
a permanent cure. The tubercular lesions of the intestinal mucous mem- 
brane that occasionally indicate treatment by laparotomy are usually found 
in the lower portion of the ileum, the ileo-cascal region, cEecum, or ascending 
colon. Tubercular inflammation of the large intestine may cause so much 
swelling as to give rise to intestinal obstruction. When the inflammatory 
process is limited to a small portion of the bowel, operative removal of the 
affected segment is justifiable and holds out a fair prospect of permanent re- 



602 PRINCIPLES OF SURGERY. 

lief. Schier reports a successful case of this kind. At the close of October, 
1887, he was consulted by a man who had a painful swelling in the right 
hypochondrium; the swelling was as large as a man's fist, with a nodular- 
surface. Considerable pain, tenderness, emaciation, and evidences of intes- 
tinal obstruction, which were gradually increasing in intensity. A tumor 
of the caecum was diagnosticated, and laparotomy was performed Novem- 
ber 1st of the same year. The abdomen was opened by a lateral incision. 
The omentum near the swelling was much inflamed and covered with 
whitish-yellow nodules, from the size of a pin to that of a pea. Twelve to 
sixteen enlarged glands, some as large as a walnut, situated along the 
vertebral column, were enucleated or removed with a sharp spoon. The 
caecum was so fragile that it ruptured during the manipulations and some 
faeces escaped. The bowel above and below the swelling, which involved 
the caecum, was emptied by expression, tied with rubber bands, and the 
affected portion excised. The part of the caecum containing the valve and 
the vermiform appendix was left. Circular suturing by a double row of 
sutures. The subsequent history of the case was favorable in every re- 
spect. Pain was severe for two days, and yielded to large doses of opium. 
Eighteen months after the operation the patient remained in good health. 
Examination of the part removed showed that the swelling was of a tuber- 
cular nature, the submucosa and external layers of the bowel being mainly 
involved. 

Durante reported a somewhat similar case. The patient was a woman, 
aged 56, who, for four or five years, had suffered from obscure pain in 
the right iliac fossa when at stool. The pain increased in intensity and 
became paroxysmal, and the patient almost starved herself, with the object 
of avoiding the torture of defecation. On examination a tumor was found 
in the right iliac fossa, extending downward toward the upper outlet of 
the pelvis. Carcinoma of the caecum or neighboring parts was suspected. 
The abdomen was opened. The swelling, as large as a lemon, was found 
adherent to the iliac fossa, the parietal peritoneum and coils of the small 
intestine being matted to it so firmly that the lower end of the latter, 
measuring 25 centimetres in length, together with the caecum and a por- 
tion of the ascending colon, was removed with it. The two ends of the 
divided intestine were brought together by* three rows of sutures. The 
abdominal wound was closed, and the patient made a rapid and perma- 
nent recovery. The swelling, which had almost completely blocked up the 
lumen of the intestine, was found to be of a tubercular nature. Since 
these cases were reported, a number of successful operations have been per- 
formed for tuberculosis of the caecum. If, in cases of intestinal tubercu- 
losis indicating laparotomy, it should be found, after opening the abdo- 
men, that the foci in the ileo-caecal region are too numerous to warrant a 



TUBERCULOSIS OF THE mammakv GLAND. G03 

radical operation by enterectomy, the symptoms can be relieved and the 
inflamed parts excluded from the fecal circulation by establishing an anas- 
tomosis between the intestine above and below the affected segment. 

TUBERCULOSIS OF Till; MAMMARY GLAND. 

A la rue number of well-authenticated cases of primary tuberculosis 
of the mammarv gland have been reported. So far as the infection is 
concerned, the breast must be considered as an appendage of the skin. 
The bacillus from without may effect entrance into the gland through 
the milk-duets, in which case the inflammatory process commences in 
the parenchyma of the gland; or it may enter through a fissure of the 
nipple, in which case the process is primarily interstitial. When direct 
infection from without can be excluded, the disease is the result of auto- 
infection, and on this account the prognosis is always more unfavor- 
able. In reference to the manner of local infection Mandry distinguishes 
two forms of primary tuberculosis of this gland. The first is very chronic, 
in which the tubercular product is circumscribed, appearing as a firm 
nodular mass, which later undergoes caseation. Abscesses, fistulae, re- 
traction of the nipple, and secondary infection of the axillary glands 
appear in the course of years. The second form is, from the beginning, 
more diffuse and resembles clinically a cold intramammary abscess. The 
disease is met with most frequently in women w T ho are nursing, but I have 
repeatedly observed it in young unmarried women. Mandry has observed 
7 cases and describes 21 others recorded. One of the 28 was in a male 
patient. Eegional dissemination takes place along the chain of axillary 
lymphatic glands. Orthmann examined the enlarged lymphatic glands 
in a case of primary tuberculosis of the mamma, and found numerous 
tubercle bacilli. The disease is differentiated from carcinoma by the 
absence of pain and hardness in the swelling and from an ordinary sup- 
purative mastitis by the absence of the prominent symptoms of acute 
inflammation. It might be mistaken for a lacteal cyst or an echinococcic 
cyst, but all doubt as to the nature of the swelling can be set aside by an 
exploratory puncture. 

Treatment. — The more expectant plans of treatment recommended 
in the management of tubercular abscesses communicating with the 
primary foci in tissues and organs deeply situated should not be fol- 
lowed in the treatment of tubercular affections of the breast, as in these 
cases a radical operation is not attended by any danger to life, and usually 
results in a permanent cure. The plan to be pursued depends on the 
extent and location of the disease. A superficial limited tubercular focus 
of the mamma can be successfully treated by excising the infected tissues. 
If the process is more deeply located, it may become necessary to remove 



604 PRINCIPLES OF SURGERY. 

a portion of the mammary gland with it. Partial excision of the gland 
should be done in such a manner as to include the tubercular focus in a 
wedge-shaped section of the gland, the base of the wedge being directed 
toward the periphery of the gland. After excision the cut surfaces of the 
gland are united with buried catgut sutures. If the disease has infiltrated 
the gland extensively, or if a number of sinuses or abscesses have formed, it 
becomes necessary to extirpate the entire gland. Enlarged glands are re- 
moved in the same thorough manner as in operating for carcinoma of the 
breast. Multiple foci necessitate excision of the entire gland. 

TUBERCULOSIS OF THE GEXITO-URIXARY ORGAXS. 

It is only within the last few years that a number of chronic inflam- 
matory processes of the genito-urinary organs in both sexes have been 
shown to be tubercular in their origin, clinical tendencies, and final ter- 
mination. The susceptibility of the mucous membrane of the genito- 
urinary tract to tubercular infection has been demonstrated experiment- 
ally by Cornet. In rubbing a pure culture of tubercle bacilli in superficial 
abrasions of the penis in dogs he produced a tubercular lesion of that 
organ. In bitches tuberculosis of the vagina and uterus could be pro- 
duced by injections of a pure culture into the vagina. The local lesions 
were followed by general tuberculosis. 

(a) Tuberculosis of Vulva, Vagina, and Uterus. — Direct tubercular 
infection of the genital tract in women has been observed, but the cases 
so far reported are few. Eobitansky believed that tuberculosis of the 
cervix uteri is always limited, while Lebert denied its existence. Paulson 
describes it as a tubercular erosion of the cervical canal, and says it never 
invades the vaginal portion of the cervix. Mosler found the uterus 
affected in 4 out of 46 post-mortems made upon women who had died of 
tuberculosis. Kolb and Hegar give similar results. With the exception 
of Friedlander, authors are inclined to hold that it usually occurs as a 
secondary affection. Barbier believes that a woman can be infected by a 
tubercular husband during coitus, as bacilli have been demonstrated in 
the semen of tubercular patients, as well as in the discharge attending 
tubercular epididymitis. The uterus may be infected by extension from 
a tubercular lesion of the vulva without any intermediate trace of infec- 
tion in the vagina. The author even admits the possibility that tuber- 
cular infection may be transmitted by the finger of the attendant, by in- 
fected instruments, or even through the medium of the air. Zweigbaum 
reports a case of primary tuberculosis of the portio vaginalis uteri which, 
at the time of examination, appeared in the shape of an ulcer the size of 
a walnut, with thick, indurated margins and cheesy floor. Numerous 
tubercle bacilli were found in the secretion taken from the surface of the 



TUBERCULOSIS OF THE GENITO-URINAR1 ORGANS. 605 

ulcer. Evidences of tuberculosis were apparenl at this time. After a lew- 
weeks the ulcer extended toward the Lefl vaginal wall. A section of a frag- 
ment of tissue removed from these parts, on staining, showed numerous ba- 
cilli. This form of tuberculosis is not frequent, as (he author could only find 
3 cases of vulvar tuberculosis in literature, although genital tuberculosis is 
quite a frequent affection. Jonin believes that tubercular endometritis from 
Local infection is quite a common affection. Of 9 cases which were observed 
by him it was due to sexual contact with men suffering from genital tubercu- 
losis. In 2 others the husbands were tubercular, but had no genital tubercu- 
losis. He calls attention to the fact that Cornil and Chantemesse have 
produced this disease artificially in rabbits by injecting bacilli into the 
vagina. Treub reports the case of a girl who had undergone all kinds of 
treatment, and finally had the uterus scraped out. The appendages then 
apj3eared to be perfectly normal. On microscopical examination the por- 
tions of endometrium removed by the curette were found to be tubercular. 
Two weeks later the patient came under Treub's care. It was then un- 
certain whether the tubes were affected. For six weeks she was treated 
by diet alone, and at the end of that time the tubes could be felt, forming 
sausage-shaped swellings adherent to neighboring parts. The uterus and 
tubes were removed through the vagina, and at the operation the peri- 
toneum in Douglas's pouch and the serous coat of the uterus were found 
covered with tubercles. A year and a half after the operation the patient 
was in perfect health. The cases of primary tuberculosis of the vulva, 
vagina, and uterus will undoubtedly become more numerous in the litera- 
ture of the near future, when improved methods of examination will 
enable the surgeon to make a positive diagnosis between these affections 
and carcinoma and syphilitic lesions. The same points in differential 
diagnosis are to be remembered in this connection as have been enumer- 
ated in the consideration of tubercular affections of the mouth. 

Treatment. — Primary tuberculosis of the utero-vaginal canal and 
vulva should be treated by curetting, and, if the extent of the lesions 
make it necessary, by cauterization with the actual cautery. Before 
either of these procedures is put into practice the parts must be rendered 
aseptic by antiseptic irrigation. Subsequent infection can be guarded 
against by the free use of iodoform, and tamponade of the vagina with 
iodoform gauze. Under ordinary circumstances it is not necessary to 
remove the tampon oftener than once a week, when the surface is again 
freely dusted with iodoform before a new tampon is inserted. 

(b) Tuberculosis of Fallopian Tubes. — In the absence of tubercular 
lesions of the vagina and uterus, it is doubtful if infection of the Fallopian 
tubes can take place by the entrance of the bacillus through the genital 
tract, and the relatively frequent occurrence of the disease in that part 



606 PRINCIPLES OF SURGERY. 

of the genital tract is only explainable by attributing it to autoinfection, 
in the same way as we have explained the occurrence, for instance, of pri- 
mary tuberculosis of joints, bone, and peritoneum. We can safely assert 
that tubercular infection of the Fallopian tubes often, if not always, takes 
place upon the basis of preexisting pathological conditions, taking it for 
granted that the healthy tubes do not present favorable conditions for 
the localization of the tubercle bacilli. A catarrhal condition of the 
mucous membrane lining the tubes, as in other organs, undoubtedly fur- 
nishes, in many instances, the locus minoris resistentice for the localization 
of bacilli brought to the part through the circulating blood or by infec- 
tion from without. Orthmann states that primary tubal tuberculosis 
occurs in 18 per cent, of all cases of tuberculosis of the female genital 
tract. 

An interesting case of primary tuberculosis of the Fallopian tubes 
has been recorded by Kotschau. The patient was 45 years old, having 
a good family history; has suffered for a year with pains in the abdomen, 
profuse metrorrhagia, and various nervous disturbances. She was treated 
for retroflexion, and subsequently had an attack of pelveo-peritonitis. 
Vaginal examination disclosed a firm, smooth, movable swelling, as large 
as an apple, to the right of the uterus; this was taken for a malignant 
ovarian growth, and laparotomy was done for its removal. On opening 
the abdominal cavity a quantity of turbid, purulent fluid escaped. The 
swelling, of oblong shape, was found lying apparently in a bed of pus; 
on account of its intimate adhesions it could not be removed. The pa- 
tient died from shock. The autopsy showed the uterus enlarged and 
retroverted. The right tube was tortuous and generally thickened. Near 
its distal end it was dilated into a swelling the size of a hen's egg, in the 
centre of which was a cavity containing cheesy material. Other small 
caseous foci were found in the tubal wall in close proximity to the large 
swelling. The ovary on the same side was enlarged and transformed into 
a caseous mass. The left tube and ovary showed similar changes, though 
less extensive. The microscopical examination of the pathological product 
confirmed the diagnosis of tuberculosis. Although the disease appears to 
have been primary in the tubes, the affection occurs more frequently from 
the direct extension of a tubercular endometritis to the tubes. Lebedeff 
gives a full description of a case that came under his observation. The 
patient was the widow of a man who had died of pulmonary tuberculosis. 
An examination before the operation revealed a firm, nodulated, intraab- 
dominal tumor in the space of Douglas. An attempt was made to remove 
the tumor by laparotomy, but had to be abandoned, as the disease had be- 
come too widely disseminated. Six weeks later the patient died with 
symptoms of general tuberculosis. At the post-mortem miliary tubercu- 



DUBEBCULOSIS OF THE GENIT0-UBJNAB7. OBGANS. 6C3 

losis was found in the peritoneum, lungs, colon, uterus, and Fallopian 
tubes. The most advanced Btages of the disease were found in the uterus 
and Fallopian tubes, showing that the disease had commenced in these 
organs. Both of the Fallopian tubes were dilated and filled with pus, the 
epithelium in parts being absent. Stained sections from the uterus and 
tubes showed the presence of numerous bacilli. 

Symptoms and Diagnosis. — Tubercular salpingitis, occurring as a sec- 
ondary lesion to a primary tuberculosis in the lower portion of the genital 
tract, can be suspected if, in connection with a cervical or endometritic 
tuberculosis, examination - reveal a swelling in the region of one or both 
Fallopian tubes. Primary tubercular disease of the Fallopian tubes gives 
rise to local conditions and symptoms that it would be impossible to differ- 
entiate from an ordinary pyosalpinx. The existence of a dilated, inflamed 
Fallopian tube can generally be made out with some degree of certainty 
by making the examination while the patient is under the influence of an 
anaesthetic. Werth has described an acute and chronic form of tubercular 
salpingitis. In the acute variety both the muscular and serous coats 
undergo caseous degeneration, numerous bacilli being found in the in- 
terior of the tube; while in the chronic form the wall of the tube under- 
goes thickening and infiltration with new cells, and its contents contain 
only a few bacilli. The increase in size of the tube is due to the collection 
of pus in its interior as well as to the thickening of the wall. When sup- 
puration takes place in the interior of the tube the tubercular product has 
become the seat of a secondary infection with pus-microbes; hence indica- 
tions for operative treatment have become more urgent. If the tuber- 
cular inflammation extend from the abdominal extremity of the Fallopian 
tube to the peritoneum, symptoms of tubercular salpingitis are obscured 
later on by those of tubercular peritonitis. 

Treatment. — As a tubercular salpingitis calls for the same treatment 
as a pyosalpinx, it is, for all practical purposes, only necessary to narrow 
the diagnosis down to either one of these two affections before resorting 
to treatment by laparotomy. A median incision is preferable to a lateral, 
as frequently both tubes are affected simultaneously. Salpingectomy 
should be combined with oophorectomy, as the ovaries are frequently im- 
plicated in the tubercular process, and these organs would be of no further 
use after extirpation of the tubes. As tubercular tubes are usually found 
firmly adherent to the surrounding tissues, their removal is often at- 
tended with the greatest difficulties, and may become an impossible task. 
If the disease is limited to the tube-structures, and has not involved sur- 
rounding important organs, it would appear rational, under such circum- 
stances, to lay the tube open, remove its contents, scrape out the infected 
tissues as far as possible, arrest bleeding by applying the actual cautery, 



608 PRINCIPLES OF SURGERY. 

and, after thorough iodoformization, pack with iodoform gauze. This 
treatment would certainly appear more rational than to be content with 
an exploratory incision and allow the patient to remain a sufferer until 
relieved by death from tuberculosis. In one case that came under my 
treatment, where both tubes were imbedded in a mass of granulation- 
tissue, I was unable to remove the entire mass, and I was compelled to pursue 
this course, and the patient recovered quickly and permanently, in spite 
of a faecal fistula that formed a few days after the operation. 

TUBERCULOSIS OF THE OVARY. 

Primary tuberculosis of the ovary is comparatively rare. More fre- 
quently the organ becomes secondarily involved by extension of the dis- 
ease from the Fallopian tube or peritoneum. Orthmann has collected 177 
cases. Only 57 were submitted to a careful microscopical examination, 
and of these 48 were typical instances of ovarian tuberculosis. The dis- 
ease was bilateral in 27 cases. The remaining 9 were tubercular ovarian 
cysts. Of the 48 cases, infection was traced to the Fallopian tube in 26 
and from the peritoneum in 22. In the 48 cases the tubercle bacillus was 
found 9 times by microscopical examination and 4 times by inoculation 
experiments. 

TUBERCULOSIS OF GLAXS PENIS AXD URETHRA. 

Kraske has observed a case of tubercular ulceration of the urethra, 
extending from the membranous portion of the neck of the bladder, in 
a patient, 33 years of age, who was treated for chancre. The autopsy 
revealed advanced tuberculosis of the genito-urinary tract and pulmonary 
tuberculosis. In another case, a man 49 years old, a tubercular ulcera- 
tion existed on the dorsum of the glans the size of a cent piece. This 
sore was also mistaken for a primary lesion of syphilis. There were no 
signs of pulmonary tuberculosis. The glans was amputated, when it was 
observed that the tubercular infiltration extended deeply into the cav- 
ernous structure. The lesion could not be traced to genital contact, and 
under the microscope showed the typical structure of tubercular tissue. 
In the examination of doubtful lesions of the glans penis it is well to 
remember the possibility of tubercular infection in this locality, and, in 
case the tubercular nature of a lesion can be established on sufficient 
grounds, to resort to cauterization with the actual cautery, excision, or 
amputation, according to the location and extent of the disease. 

TUBERCULOSIS OF EPIDIDYMIS AXD TESTICLE. 

In the male genital apparatus tuberculosis attacks most frequently 

the epididymis, for the reason that the vessels in this structure are more 



CUBEBCULOSIS 01 EPIDIDYMIS AM) TESTICLE. 

tortuous and smaller than in the remaining portion of fche testicle or the 
?as deferens, both of which are important elements in determining Locali- 
zation in that pari from floating bacilli thai reach it through the circu- 
lating blood. Salzmann states that these anatomical conditions are im- 
portant factors in the arrest and localization of floating bacilli. That in 
cases ol tuberculosis of the testicle we are only dealing with an external 
manifestation of an antecedent infection becomes apparent by the clinical 
observation that not infrequently both testicles are infected, either simul- 
taneously or some time apart, showing that the infection came from the 
same source. Guyon ("La Castration pour le Sarcocele tuberculeux,'"' 
Ann. des Mai. des Org. Gemto-urin., 1891, vol. ix, Xo. ?) believes that 
tuberculosis of the genito-urinary organs occurs quite frequently as a 
primary affection. He is of the opinion that tuberculosis of the epididy- 
mis is almost always complicated by a similar affection of the prostate and 
vesiculas seminales, and is therefore, on the whole, opposed to castration 
as a curative operation. He maintains that this operation is only justi- 
fiable after the disease of the epididymis has resulted in the formation of 
abscesses and fistulous openings. Tuberculosis of the genital organs in 
the male furnishes one of the best examples of the typical clinical course 
of local tuberculosis. The disease extends, by continuity of structure, 
often to a great distance from its starting-point. Xothing is more 
familiar than the clinical course of a case of tuberculosis of the testicle. 
A small, hard nodule is first detected in the epididymis, and from this 
point the whole structure of the epididymis is infected, when the infection 
slowly, but surely, extends to the testicle; then along the vas deferens 
to the vesiculas seminales, the prostate gland, and bladder, and from this 
viscus along the ureters to the pelvis of the kidney. As a rule, the dis- 
ease remains limited to the genito-urinary organs, but in some instances 
metastatic infection takes place, either from the genito-urinary organs 
or from the primary source of the infection. A gentleman was under my 
care whose case illustrates a number of interesting points descriptive of 
the clinical behavior of genital tuberculosis. He was 35 years of age; mar- 
ried for ten years; the marriage had been childless. He claimed that he 
never had syphilis or gonorrhoea. Tuberculosis is hereditary in the family. 
Xine years before he noticed a small, hard swelling in the epididymis of 
both testicles. Two years before symptoms of cystitis appeared, which 
were not much improved by internal medication and antiseptic irrigation 
of the bladder. Six months before his left knee became swollen and 
painful. Four months later he commenced to suffer severe pain in the 
region of the left kidney. Temperature varied from 100° to 103° F. A 
swelling soon formed in the left lumbar region, and four weeks later I 
evacuated a large quantity of pus through a lumbar incision. Through 



610 PRINCIPLES OF SURGERY. 

the incision the kidney could be seen and felt, and, by passing the index 
finger around it, it appeared to be extensively separated from the con- 
tiguous structures. The left knee presented all the appearances of ad- 
vanced synovial tuberculosis. jSTo evidences of pulmonary tuberculosis. 
The disease in both testicles had made no progress for years, and the 
infiltration appears to be limited to the epididymis. The epididymis on 
both sides is moderately swollen and indurated. The vas deferens on 
each side is somewhat larger and firmer than normal. The disease had 
extended from the epididymis to the pelvis of the kidney on both sides, 
all of the intervening organs being involved in the tubercular process. 
The only apparent manifestation of general tuberculosis was presented 
by the left knee. An interesting feature in this case was the formation of 
a paranephritic abscess around a pyelonephritic kidney, which must be 
regarded as the result of a secondary infection with pus-microbes. 

Symptoms and Diagnosis. — Tubercular epididymitis always appears 
as a chronic affection, in this respect differing from gonorrhceal epididy- 
mitis and the ordinary form of acute parenchymatous and suppurative 
orchitis. Pain and tenderness are either entirely absent or, at least, 
slight when present. Circumscribed hydrocele may develop as soon as 
the disease extends to the tunica vaginalis. The tubercular inflamma- 
tion is characterized by the same pathological conditions as in other 
organs, new nodules appearing in the neighborhood of the first one, which, 
by confluence, form masses of considerable size. Caseation is an early 
and almost constant condition. In many cases the process extends in the 
direction of the skin; a tubercular abscess forms in the tunics of the 
scrotum; the skin presents a bluish-red color, and spontaneous perfora- 
tion gives rise to evacuation of the abscess. Frequently multiple abscesses 
form in this manner, and the fistulous openings lead down to caseous 
masses. In some cases, as the one reported, the disease in the epididymis 
becomes latent, but the infection extends at an early date along the vas 
deferens, which becomes swollen, hard, and nodular, and from which, if 
a cross-section is made, the characteristic cheesy material can be squeezed. 
From the vas deferens the disease extends to the vesicular seminales, pros- 
tate gland, bladder, and finally creeps along the ureters to the pelvis of 
the kidney, usually simultaneously on both sides. The only disease wjth 
which tubercular epididymitis might be confounded is tertiary syphilis 
affecting the same part of the testicle. In cases of doubt the patient 
should be placed on antisypfiilitic treatment for a few weeks, which, if 
the affection is tubercular, will produce no impression on the swelling; on 
the other hand, if it is syphilitic, it will rapidly diminish in size. 

Treatment. — The only radical treatment in tuberculosis of the epi- 
didymis and testicle is castration. This operation is indicated if the dis- 



TUBERCULOSIS OF THE v ksht I..K SEMINALES. 6U 

ease is limited to one testicle, and no evidences of tuberculosis can be 
found in any other organ beyond the reach of surgical treatment. I have 
removed both testicles in two cases, bu1 in both patients tubercular cys- 
titis developed one and two years, respectively, alter the operation, and 
in one of them the immediate cause of death was pulmonary tuberculosis. 
My own cases and the experience of other surgeons would tend to dictate 
a conservative course of treatmenl it' both testicles are affected. In per- 
forming castration for malignant or tubercular affections of the testicle 
the surgeon should aim to remove as much of the spermatic cord as 
possible. The inguinal canal should be laid open freely and, by patient 
traction on the cord, as much as possible of this structure beyond the 
internal inguinal ring should be secured and removed. After the disease 
has extended to the organs at the base of the bladder or the bladder itself, 
castration is, of course, positively contraindicated. Reboul, of Marseilles, 
treated three cases of this disease by injections of naphthol-camphor. He 
injected 4 to 5 drops every eight to ten days into the thickened tissues of 
testicle and epididymis. Marked improvement was effected, the diseased 
parts becoming more indurated and contracted; and these results are the 
more noteworthy since in two of the cases other measures continued for 
a long time had been unsuccessful. The coexistence of pulmonary tuber- 
culosis, or tuberculosis of any of the larger joints, would furnish a suffi- 
cient ground against the propriety of castration. Castration is a legiti- 
mate operation, and yields fair results if the patient is otherwise in good 
health and the disease is limited to one side, and has not extended along 
the cord beyond a point where all of the infected tissues can be removed. 
The tunica vaginalis should always be removed with the testicle, and, if 
the scrotum is adherent at any point, the adherent portions of the skin 
must be excised at the same time. The vessels of the cord should be 
tied separately, as tying the cord en masse gives rise to unnecessary pain, 
and the ligature is liable to slip: an occurrence that might be followed by 
troublesome haemorrhage. If the disease is bilateral and has resulted in 
abscess formation much can be gained by the vigorous use of the sharp 
spoon followed by the local use of iodoform. Recently much has been 
said in favor of resection of the tubercular epididymis as a substitute 
for castration, but it is very doubtful if the claims advanced will be sup- 
ported by clinical experience. 

TUBERCULOSIS OF THE YESICUL.E SEMIXALES. 

In 1829 Dahmar described a chronic inflammation of the seminal 
vesicles, the description of which corresponds closely to that of tuber- 
culosis. Since then this affection has been described by Albers, Jaye, 
Xaumann, Humphrey, and Kocher, and lately it has been studied by 



612 PEINCIPLES OF SURGEBY. 

Kayer, Cruveilhier, and Keclus as secondary to pulmonary tuberculosis. 
As a secondary affection this ailment is not only seen in connection with 
tuberculosis of the lungs, but is more common after primary tubercu- 
losis of the epididymis, either as a continuation of the cheesy degenera- 
tion in the vas deferens or spreading by contiguity of tissue from the 
sides of the prostate. Primary tuberculosis of these organs is extremely 
rare, and still less often diagnosed, and up to quite recently no surgical 
interference has been attempted. Ullmann now reports a case of primary 
tuberculosis of the right testicle, with secondary affection of the seminal 
vesicles on both sides, in a lad 17 years of age, where, after removal of 
the right testicle, he extirpated these organs through a semilunar incision 
in the perineum. The general health of the patient improved after the 
operation, but a small urinary fistula remained, which formed in conse- 
quence of injury to the base of the bladder during the operation. He is 
of the opinion that the seminal vesicles should be removed in primary 
tuberculosis of the testicle or epididymis, when no suspicious symp- 
toms have appeared on the sound side, and when on the affected side 
the vesiculaa seminales are already attacked; also in cases of primary 
tuberculosis of the seminal vesicles. Fenger has also reported a successful 
extirpation of the vesiculaa seminalis for tuberculosis. More recently Eoux, 
of Paris, has advanced the idea that in tuberculosis of the genital organs it is 
a mistake to remove only the testicles, since he has often observed fistulse and 
abscesses extending along the cord after castration. He advises, in addi- 
tion, extirpation of the vas deferens and seminal vesicles. He reports 
two cases in which, after removal of the testicle, the vas deferens was 
carefully separated from the vessels of the spermatic cord, which were 
then tied and divided. An incision was then made in the perineum, the 
vesiculae seminales pushed into the wound by the finger introduced into 
the rectum and excised, and the vas deferens entirely removed. The re- 
sults were excellent. The impotence following the operation should be 
no contraindication, for in all reported cases of tuberculosis of the seminal 
vesicles impotence always occurs in a short time; in fact, it is regarded as 
a cardinal symptom of the disease. 

TUBEECULOSIS OF THE BLADDER. 

Tuberculosis of the bladder occurs either as a primary or secondary af- 
fection. Several cases of well-marked primary tuberculosis of the bladder in 
the female have come under my observation, where the disease evidently 
commenced at the neck of the bladder, and, after spreading over the whole 
internal surface of the viscus, extended along the ureters to the pelves 
of the kidneys, and finally, in the course of a few years, proved fatal from 
tubercular pyelonephritis. Primary tubercular cystitis appears to be more 



I'l BERCULOSIS OF THE BLAI>DER. 613 

frequenl in females than in males, undoubtedly because, on account of 
shortness of the urethra, dired infection is more liable to occur. 

Striimpell, after a careful study of 1 cases of primary tuberculosis 
of the bladder in men. came to the conclusion that infection takes place 
through the urethra. The tubercle bacilli, finding no favorable place for 
localization and growth in the urethra and bladder, finally reach the 
prostate gland or the epididymis, the whole process resembling what 
occurs in inhalation tuberculosis, in which the disease manifests itself 
not in the mucous membrane of the bronchial tubes, but in the paren- 
chyma of the apices of the lungs. 

More frequently, however, tubercular cystitis follows a descending 
tubercular ureteritis or in consequence of an extension of a tubercular 
process from the epididymis along the spermatic cord to the vesiculaa semi- 
nales, prostate gland, and base of the bladder. If the disease reach the 
bladder from above, the mucous membrane around the ureteral orifice is 



V 



Fig. 200.— Tubercle Bacilli in Urine. 

first involved, and from here the disease spreads over the mucous surface 
of the organ. On the other hand, infection from below is first manifested 
by symptoms which indicate irritation and inflammation of the neck of the 
bladder. 

Symptoms and Diagnosis. — Tuberculosis of the bladder is clinically 
characterized by symptoms of cystitis, the intensity of the symptoms 
varying according to the part of the bladder affected, the extent of the 
disease, and the presence or absence of complications. If the disease 
primarily involve the neck of the bladder, tenesmus and frequent desire 
to urinate are the most distressing symptoms. As long as no ulceration 
of the vesical mucous membrane has taken place, the urine may present 
a perfectly normal appearance, and, on examination, is found normal in 
other respects. Slight attacks of hematuria are of frequent occurrence. 
Very frequently the symptoms become very much aggravated shortly after 
an examination of the bladder, made upon the supposition that the patient 
is suffering from stone in the bladder, as the introduction of a sound 



614 . PRINCIPLES OF SURGERY. 

without the necessary aseptic precautions is often followed by a sec- 
ondary infection with pus-microbes, which gives rise to an acute sup- 
purative cystitis. The general health of the patient now becomes rapidly 
undermined, and the extension of the local disease in the direction of 
the kidneys is hastened. The urine contains large quantities of pus and 
mucus, and becomes ammoniacal from the presence and action of putre- 
factive bacteria. The walls of the bladder become greatly thickened from 
inflammatory exudation and tubercular infiltration; the organ is unable 
to empty itself completely, and the decomposed residual urine becomes 
an additional source of irritation and progressive infection. Incontinence 
of urine is a frequent symptom in advanced vesical tuberculosis, and is 
usually an indication that the organ is extensively diseased. In secondary 
tuberculosis of the bladder it is usually not difficult to locate the primary 
disease, and thus establish a positive diagnosis. The presence of tubercle 
bacilli in the urine in cases of primary tuberculosis of the organ fur- 
nishes a positive diagnostic criterion between ordinary cystitis and 
vesical tuberculosis. In the absence of the ordinary caiises of cystitis, such 



Aa\ mm. 




7 

Fig. 201.— Tubercle Bacilli in Urine. (Coniil and Babes.) 

as gonorrhoea, stricture of the urethra, enlarged prostate, calculus, and 
tumors of the bladder, symptoms of cystitis point strongly toward a 
tubercular origin of the inflammation, and should induce the surgeon to 
make a most careful examination in reference to the etiology and nature 
of the cystitis. It is only by excluding the presence of the different lesions 
of the bladder by a careful and thorough examination of that viscus and its 
neighboring organs, as well as a chemical, microscopical, and bacterio- 
logical examination of the urine, that a positive diagnosis of vesical 
tuberculosis can be made during the early stages of the disease. In tuber- 
culosis of the pelvis of the kidney or bladder free bacilli can often be found, 
and sometimes their presence can be detected in the cells. Tubercular 
urine injected into the peritoneal cavity of a guinea-pig will produce 
tuberculosis in this animal, and in doubtful cases this diagnostic measure 
may prove of great value. 

Prognosis and Treatment. — In secondary tuberculosis of the bladder 
the regional infection has extended so far that even the most heroic 
surgical measures will necessarily fail in eliminating the disease, .and 



rUBERCULOSIS OF THE BLADDER. 615 

death from extension of the infection to the kidneys, or from secondary 
pulmonary or general tuberculosis, will follow as an inevitable result. In 
primary vesical tuberculosis the disease, at the time a positive diagnosis 

can be made, has usually invaded so much of the walls of the bladder 
that a radical operation would necessitate an extensive resection of its 
walls, after which it would be found impossible to utilize the remaining 
portion o( the organ as a reservoir for the urine. Resection of the wall 

of the bladder has been done in several instances in the treatment of 
malignant tumors at its base, but has usually terminated in the formation 
of a permanent urinary fistula. 

Dr. 1\. Harvey Reed, of Mansfield, Ohio, made an interesting scries of 
experiments on dogs, with a view to dispense with the bladder altogether in 
cases of extensive disease of this organ, necessitating partial or complete ex- 
cision. He has shown that the ureters can be successfully implanted into the 
rectum, thus excluding permanently the urinary tract below this point from 
the urinary passages, and utilizing the rectum as a reservoir for the urine. If 
the operation of implantation of the ureters into the rectum can be perfected 
to such an extent as to become a feasible and practical procedure in surgery 
it may be possible, in the future, that vesical tuberculosis can be successfully 
dealt with by complete excision of the affected organ. Implantation of both 
ureters into the sigmoid flexure has been successfully performed by Dr. C. 
Beck, of Chicago, and others for vesical tuberculosis, and this operation or a 
modification of it recommends itself in cases in which the tubercular affec- 
tion is limited to the bladder. It appears to me the implantation of the 
right ureter into a healthy appendix vermiformis and implantation of the 
left into the sigmoid flexure would be a feasible operation, and, if per- 
formed in two stages, would greatly reduce the immediate sources of 
danger. 

The conservative treatment of vesical tuberculosis by injection of 
solutions of boric acid, benzoate of soda, the ordinary antiseptic solu- 
tions, and iodoform has little or no effect, either in affording palliation or 
in retarding the regional extension of the disease. Guyon recommends 
corrosive sublimate as an excellent remedy in cystitis, but especially in 
vesical tuberculosis. The remedy is employed either in the form of irri- 
gation or instillation, the latter being preferred by the author. The 
strength of the sublimate solutions varied from 1-5000 to 1-1000. At 
the beginning of treatment 20 to 30 drops are injected into the posterior 
urethra, and this quantity is gradually increased to 60 drops. The more 
severe the pain, the less should be the quantity injected. Before the 
instillations the bladder must be emptied. The remedy that has ) T ielded 
better results in my hands than any other in the local treatment of vesical 
tuberculosis is trichloride of iodine. The treatment must be commenced 



616 PRINCIPLES OF SURGES Y. 

with a very weak solution, — a / 4 per cent., the strength gradually in- 
creased to 1 per cent, as the bladder becomes more tolerant to the action 
of this drug. The bladder should first be washed out with sterilized water 
and not more than an ounce of the solution injected at a time. Eeniac 
reports cases of tubercular cystitis treated by instillation of 1 ounce of 
liquid vaselin containing 25 grains of iodoform. The oily material floats 
upon the urine. When the patient micturates the urine at first escapes 
free from oil, but toward the end of the act it appears, and as soon as this 
is the case further escape ceases. In this manner the iodoform is detained 
in the bladder many days. When it disappears a new instillation is made. 
Iodoform thus used relieves pain and promotes the healing of the ulcera- 
tions. He gives the particulars of 14 cases treated by this method, of 
which number 7 were greatly improved, 6 considerably benefited, 1 not im- 
proved. Internal medicines — such as boric acid, benzoate of soda, uva ursi, 
buchu, triticum repens, and urotropin — are of utility in relieving vesical 
tenesmus, before secondary infection with pus-microbes and putrefactive bac- 
teria has occurred, by rendering the urine alkaline and more copious; 
but during the later stages of the disease they are useless even as palli- 
atives. If the tubercular process is limited to the urinary passages below 
the ureters, incision and drainage of the bladder secure rest to this organ 
and open up a direct route for the more effectual treatment of the tuber- 
cular lesions, and thus not only constitute the most efficient palliative 
measure, but also the most effective procedure in retarding the local ex- 
tension of the disease by direct, vigorous, antitubercular treatment. I 
had an opportunity to observe the palliative effect of an opening in the 
bladder, in a case of primary vesical tuberculosis in a female aged 35 years, 
where the tubercular ulceration resulted in the formation of a vesico- 
vaginal fistula. The tenesmus was promptly relieved, as soon as the 
bladder was placed in a condition of rest, by the escape of urine through 
the fistulous opening. 

In the female the most direct route into the bladder, and affording 
the most efficient drainage and furnishing the most advantageous condi- 
tions for the local treatment of the tubercular lesions, is a vaginal cys- 
totomy made near the neck of the bladder. The opening should be at 
least 1 1 / 2 inches in length, extending from near the neck of the bladder 
in an upward direction. Tubular drainage should be dispensed with, as 
all foreign substances in the bladder not only act as irritants, but inter- 
fere with complete drainage. As the opening is made in the most de- 
pendent portion of the bladder, free drainage can be secured most effi- 
ciently by means which prevent contraction or closure of the vesico- 
vaginal opening. This can be done by suturing the mucous membrane of 
the bladder to the vaginal mucous membrane, thus establishing a perma- 



TUBERCULOSIS OF THE KIDNEY. ,; 1 3 

unit bimucous fistula between the bladder and the vagina. Through this 
opening accessible tubercular Lesions can be treated by the use of the 
sharp spoon and the direci application of iodoform. The parts below this 
opening should be protected againsl the irritating effect of urine by 
applications o( vaselin or lanolin containing one of the milder antiseptic 
remedies. A t'tor the fistulous opening has been established the bladder can 
be irrigated with antiseptic solutions, or a mixture containing iodoform, 
through the urethra. 

In the male the same objects are attained more efficiently by making 
a suprapubic cystotomy, as through a perineal incision the direct treat- 
ment of tubercular lesions is impossible. The fistulous communication 
should be made complete by suturing the margins of the visceral wound 
to skin-flaps taken from each side of the external incision: a method first 
suggested by Morris, of New York. By lining the margins of the incision 
with mucous membrane and skin, the loose connective tissue in the pre- 
vesical space is protected against infection, and the fistulous opening is 
rendered permanently patent. At the time of operation visible tubercular 
ulcers are curetted and iodoformized. The bladder can be irrigated sub- 
sequently through the urethra or through the fistulous opening. 

In a case of advanced primary tuberculosis of the bladder where I 
pursued this method of treatment the operation afforded marked relief, 
but appeared to have no influence in retarding a fatal termination, as the 
disease had already extended to the kidneys. The patient lived for nearly 
two months in comparative comfort, the principal complaint made being 
the moisture caused by the constant escape of urine through the artificial 
urethra. 

A case is described by Battle in which recovery followed curetting 
through # a suprapubic incision, after the failure of less formidable means. 
The patient was a girl aged 20 years. The operation was performed July 
29, 1889. The patient was discharged September 20th, and April 8, 1890, 
was in good health and working at her trade. 

In cases where the disease in the bladder is circumscribed, and the 
organ is opened early, the treatment might, occasionally at least, result 
in a permanent cure, if the infected tissues can be completely removed 
by curetting or destroyed by the actual cautery through the incision at 
the time of operation. In such favorable cases the opening should not 
be allowed to close until the surgeon can satisfy himself that the ulcers 
have completely healed, and that no new centres of infection are present. 

TUBERCULOSIS OF THE KIDNEY. 

The frequency with which the kidneys are affected by primary 
tuberculosis remains a much disputed question. James Israel is of the 

39a 



618 PRINCIPLES OF SURGERY. 

opinion that primary tuberculosis of the kidney is much more frequent 
than secondar}-, while other equally competent authorities entertain an 
opposite view. The fact, however, remains that primary renal tubercu- 
losis is much more prevalent than was formerly supposed. The disease 
may have its starting-point either in the substance of the kidney or in the 
pelvis. It is characterized clinically by pain and tenderness in the lumbar 
region and along the course of the ureter, hematuria, tubercular tissue 
in the urine, and at an early stage by vesical irritation. If the ureter 
becomes obstructed tubercular pyonephrosis follows. It is not always easy 
to differentiate between vesical and renal tuberculosis and tubercular 
pyelonephritis and stone in the kidney. The microscope is a valuable 
diagnostic resource in such cases. Tuberculosis of one kidney may eventu- 
ally involve the opposite organ by extension of the disease along the 
ureter to the bladder and from the bladder to the opposite kidney by an 
ascending ureteritis. In cases in which the disease is limited to one kid- 
ney an early nephrectomy is the proper treatment. If the opposite kid- 
ney or the bladder, or both, are involved a nephrotomy is indicated, fol- 
lowed by injections into the pelvis of the kidney of antibacillary remedies, 
such as the trichloride of iodine or iodoform. 

TUBERCULOSIS OF THE VASCULAR SYSTEM. 

Mention has already been made of tuberculosis of the heart-muscle. 
It is well known that tuberculosis caused by tubercular emboli or localiza- 
tion of tubercle bacilli from the circulating blood begins as an intra- 
vascular lesion. In a classical monograph on tubercular meningitis 
Hektoen gave an accurate description of the histogenesis of the endo- 
vascular tubercle. Few observations of tubercular lesions within the large 
blood-vessels and heart have been recorded. Leyden found -tubercle 
bacilli in the vegetations of 4 oases of recent verrucous endocarditis; the 
bacilli were found chiefly in the cells. Hanot and Levi report a case in 
which tubercle of recent origin was found projecting upon the intima of 
the aorta at a point between the origin of two intercostal arteries. The 
patient, a man 61 years old, died of pulmonary tuberculosis. 



CHAPTEB XXIV. 

Actinomycosis EOMINIS. 

Actinomycosis is a form of chronic inflammation caused by the 

nee o{ actinomyces, or ray-fungus. Until quite recently this disease 
was included among the malignant tumors, and we have reason to be- 
lieve that, in many of the reported eases after operations for sarcoma, the 
disease for which the operations were done was not sarcoma, but actino- 
mycosis. Before degeneration of the inflammatory product has taken 
place actinomycosis resembles a tumor more closely than any other in- 
flammatory swelling. The swelling is composed largely of granulation- 
tissue, which, on examination under the microscope, presents an histo- 
logical structure that, in the absence of other evidences, it would be diffi- 
cult or impossible to differentiate from a round-celled sarcoma. The pres- 
ence of the specific fungus in the granulation-tissue settles the diagnosis. 

HISTORY OF THE DISEASE. 

The disease, as occurring in cattle, was first described by Bollinger, 
in 1877, as a condition in which sarcoma-like tumors were met with, 
associated with a peculiar growth which, from its structure, was named 
"Strahlenpilz" (ray-fungus), or actinomyces. James Israel was the first 
to recognize the disease in man, but it was not generally understood until 
the appearance of the classical work of Ponfick ("Die Aktinomykose 
des Mensehen," Berlin) in 1882. Numerous articles on this subject have 
since appeared in the current medical literature; so that Partsch, in 
1888, mentioned in his monograph seventy-five references, with a supple- 
mental list of thirty-three names furnished by Schuchardt. Since the 
publication of Israel's case numerous cases have been reported by differ- 
ent observers, representing Germany, England, Belgium, Switzerland, 
Russia, Austria, France, and America; so that Partsch in his paper esti- 
mates the whole number up to that time at not less than one hundred, 
and the number of cases during the last twelve years has reached several 
hundred. While most of the articles in medical journals contain only a 
description of isolated cases, it appears to have been the good fortune of 
some of the writers on this subject to meet with a number of cases in a 
comparatively short time. Thus, Hochencgg reports 7 cases that came 
under his observation, and Moosbrugger has increased the list of pub- 
lished cases by 10 well-authenticated and carefully-recorded cases. Potter 
observed 13 cases in two years. Albert has seen not less than 38 cases 

(619) 



620 



PRINCIPLES OF SURGERY. 



of actinomycosis in man within the past few years; of these, 8 have come 
under his observation during two years. These cases have come mostly 
from Vienna and its vicinity. 

DESCRIPTION OF FUNGUS. 

The ray-fungus is represented by a large family, many members of 
which are not pathogenic; many of them are saprophytic. The remarks 
here will be limited to the pathogenic variety, and more especially to the 
typical actinomycosis. Hektoen has contributed a very valuable paper to 
the flora of the ray-fungus and the histology of the actinomycotic process. 




THBF 

Fig. 202. — Ray-fungus, with One of the Rays More Projecting and Branching. (Ponfick.) 

The actinomycetes are widely distributed fungi. They have been isolated 
from the air, water, soil, and from vegetable matter, especially parts of 
grain, such as the chaff of rye, wheat, barley, and oats. Actinomycelial 
masses have been found in various parts of the body, under normal con- 
ditions, both in man and animals. Veterinary surgeons have discovered 
them in the tonsillar crypts of the hog, usually attached to fragments of 
cereals. Hektoen found such masses 4 times in a series of 100 tonsils 
examined in the laboratory of Eush Medical College. 

The ray-fungus, or actinomyces, is not, strictly speaking, a microbe, 
as it is large enough to be seen with the naked eye; but its identity can 
only be ascertained from its characteristic structure, which requires the 



DES< Kl i'i'l<>\ OF Fl NG1 S. 



621 



if the microscope. Bollinger described aa peculiar to this disease 
certain yellow bodies, visible to the naked eye, always found In 11)*' pus 
of actinomycotic abscesses and in the granulation-tissue before suppura- 
tion had occurred. Microscopically, they were found to consist of threads 
similar to the ordinary mycelium, which terminated in bulbous ends. 

The threads radiate from the centre, and their clubbed extremities 
impart to the fungus the characteristic ray-like appearance. Sometimes 
i'ut one of these bulbs is connected with a thread; at other times there 




Fig. 203. — Actinomycelial Granules in Crypt of Normal Human Tonsil. X 125. (Hektoen.) 



may be several. In some specimens one of the rays projects far beyond 
the others and terminates by several bulbous ends, as is shown in Fig. 202. 

A typical ray-fungus develops from small, round spores, or conidia, 
into solid cylindrical threads which branch and form a net-work, each 
single thread with its branches representing a single organism. From 
the surface of the mycelial layer spring hyphae, or air-threads, which 
-mentation give origin to short chains of spores which secure the 
propagation of the plant. 

The majority of the ray-fungi are aerobic and facultatively anaerobic. 
Berestneff properly divides the fungi of typical actinomycosis into two 



622 PRINCIPLES OF SURGERY. 

large groups, the first forming long branching threads with a radiating 

appearance on culture-media, the second being the polymorphous micro- 
phytes of "Wolff and Israel and others, the younger colonies of which are 
largely composed of cocci-like and rod-shaped masses, branching threads 
being formed only on special media or in old cultures. 

In man the actinomyces occurs as a small, globular mass, commonly 
about the size of a millet-seed, usually of a pale-yellow color, but at times 
white, brown, green, or speckled, the color being influenced by age and 
the consecutive pathological conditions by which it may be surrounded. 
In man the clubbed bodies are often absent, and the growth then consists 
of the radiating filaments alone. The rays, when immersed in water or 
in a weak solution of chloride of sodium, become enormously swollen and 
lose their shape; while they effectually resist the action of acids, ether, 
and chloroform. 

,B 




Fig. 204. — Actinomycosis of Liver. A, actinomyces, . 
leucocytes; C, nuclei of liver-cells. 

Clinical experience and bacteriological research appear to prove that 
infection in animals and man can take place with fragments of actino- 
myces, and that the resulting pathological conditions are the same as 
when the whole fungus is inserted into the tissues. Gross observed the 
polymorphous character of the actinomyces which could present them- 
selves in the form of single bacilli or rods, while the well-known club 
shapes were absent. Ponfick has regarded the fungus as a polymorphous 
bacterium since 1851. He is agreed as to the influence of particles of the 
fungus in the production of the disease, and in support of this view re- 
lates the case of a boy who had swallowed a bristle. Some months later 
an actinomycotic abscess formed upon the back, in which, on opening, 
the bristle was found. 

Staining'. — For staining the actinomyces, Weigert uses Wedl's orseille: 
Marchand, eosin: Dunker and Magnussen, cochineal-red: Moosbruo-o-er, 



DESCR] PTION OF PI NG1 S. 623 

ha?matoxylin-alum; and Partsch, in Bection-staining, has had the best re- 
sults with Gram's method. Babes has made beautiful dry preparations 
by using a 2-per-cent. solution of safranin in aniline-oil, followed by treat- 
ment with iodide o\' potassium. 

o. [srae] has found thai a solution of orcein in acetic acid stains the 
rays a Bordeaux red, while the filaments, if deeolorization is not carried 
too far. present a blue tinge. Baranski uses picrocarmine for staining 
fresh preparations of actinomyces bovis. A small amount of the contents 
ol' a yellow nodule, or pus from the part, is spread in a thin layer on a 
cover-glass and dried in the air. The cover is then passed three times 
through the flame of an alcohol-lamp, care being taken not to overheat 




Fig. 205. — Actinomyces from a Section of a Maxillary Tumor of a Cow. (Weigert's 
method. Orseille and gentian-violet. Zeiss V12 o.i., ocular 4.) (After Crookshank.) 

the preparation. It is then floated in the picrocarmine solution, or a few 
drops of the staining fluid are placed on the cover. The whole process of 
staining is completed in two or three minntes. The cover is then care- 
fully washed by agitating it in distilled water and alcohol, and examined 
in water and glycerin. The fungus takes a yellow color, while the re- 
maining structure appears red. 

The polymorphous variety can be successfully stained by Gram's 
method. 

Cultivation Experiments. — It has been found extremely difficult to 
cultivate the actinomyces outside of the body, probably on account of 
the usual culture-media not being well adapted for its growth. The first 
successful experiments were made in 1880 by Bostrom, of Giessen, upon 



624 PRINCIPLES OP SURGERY. 

plates of coagulated blood-serum and agar-agar, the fungus attaining its 
maturity in five or six days, when it presented the typical structure of 
actinomycosis as found in man. 0. Israel cultivated the fungus success- 
fully upon coagulated blood-serum. Upon this medium the culture grows 
very slowly and the fungus often undergoes calcification. Israel made 
the observation that water, glycerin, blood-serum, and weak saline solu- 
tions seriously impair the vitality of the fungus, and he maintained that 
the effect of these agents on the actinomyces explains the failure of pre- 
vious culture and inoculation experiments. If evaporation is prevented, a 
thin, velvety layer forms on the surface of the blood-serum* in about eight 
weeks, in the vicinity of which, not before the expiration of fourteen days, 
cell-nodules appear more in a downward direction than on the sides of the 
inoculation-streak. From the tenth to the fourteenth day numerous 
spores are produced and a thick wall of club-shaped mycelia in typical 
centrifugal arrangement. 

At a meeting of the medical society of Berlin, March 5, 1890, M. 
Wolff made a communication in which he described culture experiments 
with actinomyces which he made jointly with James Israel. He an- 
nounced that they had succeeded in cultivating the fungus in and upon 
coagulated albumen of egg and agar-agar. The material used was taken 
from a case of retromaxillary actinomycosis immediately after the abscess 
was incised. With the yellow granules stab and streak inoculations 
were made, using agar-agar as a soil. It was found that the actinomyces 
is not a purely anaerobic fungus, as it grew upon the surface as well as 
in the depth of the culture-soil. The agar culture appeared first as trans- 
parent little drops, which, by confluence, made an opaque, white mass. 
Under the microscope the culture was seen to be composed of short, thick 
rods, with an admixture of other elements. The egg cultures, on the 
other hand, were made up of short, thick rods besides a mass of threads, 
some of them twisted in the shape of a cork-screw, presenting an in- 
tricate net-work of threads. With these cultures successful inoculation 
experiments were made. The nutrient medium that yields the best re- 
sults and is now in general use is glycerin-agar. 

Inoculation Experiments. — In 1883 James Israel succeeded in pro- 
ducing the disease artificially in a rabbit by introducing a fragment of 
actinomycotic tissue into the peritoneal cavity. Somewhat later Ponfick 
made successful inoculation experiments in calves by implantation of in- 
fected granulation-tissue under the skin into the abdominal cavity or 
directly into veins. Potter experimented on calves, pigs, dogs, guinea- 
pigs, and rabbits, and in only one instance, a rabbit, did he succeed in 
reproducing the disease. In this case a piece of granulation-tissue the 
size of a bean was inserted into the peritoneal cavity, and the animal, 



SOURCES OF INFECTION. 625 

haying manifested no symptoms of disease, was killed six months after 
the inoculation. On opening the abdominal cavity, about twenty nodules, 
varying in size from the head of a pin to a hazel-nut, were found dis- 
tributed over a considerable surface around the graft, each of them 
showing the typical histological structure of actinomycosis. The trans- 
planted piece of tissue was found perfectly capsulated in one of the 
nodules the size of a bean. As the fungus was found in all the nodules, 
it is only reasonable to conclude that the disease spread from the original 
focus by migration of some of the new fungi, which, at their respective 
points of localization, established independent centres of infection and 
tissue-proliferation. While the actinomyces in the new nodules presented 
a perfect structure, and could be readily stained, the transplanted fungus 
in the graft had lost its structure, and could no longer be stained. The 
first successful inoculation experiments with pure cultures were made 
by Wolff and James Israel. Three rabbits were inoculated by injecting 
a pure culture into the peritoneal cavity. The post-mortem showed 
numerous nodules upon the parietal peritoneum, the omentum, and be- 
tween the intestinal coils. The nodules varied in size from the head of a 
pin to that of a hazel-nut, and each of them was surrounded by a fibrous 
capsule. The interior of each nodule was composed of a yellow mass the 
consistence of tallow. Typical actinomycetes were found imbedded in 
masses of round cells in a state of fatty degeneration. 

In a later series of experiments the same author inoculated 23 
animals with a pure culture grown upon sterilized agar-agar. Of the in- 
oculated animals, 18 were rabbits, 3 guinea-pigs, and 1 sheep. In most 
of them it was done in the peritoneal cavity. In every instance the 
result was positive except in the sheep. Pure cultures were made from 
the inoculation product. At the Tenth International Medical Congress 
Gross, of Krakau, reported a case of actinomycosis of the sternum, with 
the pus of which he had made an inoculation into the anterior chamber 
of the eye, with positive results. At the same meeting Hanau stated 
that he had inoculated the anterior chamber of the eye with actinomy- 
cotic material, with the same positive results. 

SOURCES OF INFECTION. 

As regards the history of the parasite outside the body, as yet only 
a few facts are known. It is found in pig-meat, and is peculiarly sus- 
ceptible to outside influences. Virchow found the fungus as a small, cal- 
careous concretion in the muscle-fibres of the pig, and considered its flesh 
highly dangerous as food unless well cooked. As the actinomycetes found 
in man and beast resemble each other morphologically and in their effect 
on the tissues, as well as in their reaction to chemical substances, it is 



626 PRINCIPLES OF SURGERY. 

evident that the etiology of the disease is similar in both. The fungus 
has never been found outside of the body. Israel is of the opinion that 
both man and animals are infected from the same source, such as veg- 
etables or water. Jensen traced an epidemic in Seeland to the eating of 
rye grown on land recently reclaimed from the sea; and Johne discovered 
a fungus closely resembling the actinomyces in grains of rye stuck in the 
tonsils of pigs. That the ears of barley or rye are sometimes the carriers 
of the fungus is well illustrated by the case reported by Soltmann. The 
patient was a boy who had swallowed an awn of barley. The foreign body 
lodged in the pharynx, where it gave rise to difficulty in deglutition; after- 
ward it perforated the pharyngeal wall, — an accident attended by haemor- 
rhage, — and later an actinomycotic phlegmon developed; it spread rapidly, 
and finally opened below the scapula. Through this opening the foreign 
body was extracted. Piana examined the tongue of a cow suffering from a 
circumscribed actinomycosis of this organ, in which the disease could 
be traced to a similar origin: perforation of the tissues and infection 
by a sharp beard of an ear of barley. That actinomycosis prevails 
in an endemic form is well shown by the investigations of Preusse. He 
examined 244 cattle and found 23 affected by some form of the disease. 
He attributes the affection to feeding the cattle with straw and hay that 
had been spoiled by submersion. He was, however, not able to find the 
fungus in the fodder. Actinomycosis has as yet only been found among 
herbivorous and omnivorous animals, including man, and the frequent 
location of the primary swelling in the mouth seems to indicate that the 
fungus gains entrance with food. Infection in man usually takes place 
through the tonsils, carious teeth, punctured wounds, by inhalation and 
ingestion of food containing the fungus in an active state. 

PATHOLOGY AND FORBID ANATOMY. 

As to the manner in which the fungus exerts its pathogenic action 
much yet remains to be ascertained. The most striking effect is the trans- 
formation of mature connective tissue into embryonal or granulation- 
tissue. The fungus possesses no pyogenic properties. It gives rise in the 
tissues to a low grade of chronic inflammation, and becomes imbedded in 
the specific product of tissue-proliferation: granulation-tissue. 

The product of inflammation around each fungus consists of granu- 
lation-tissue, which, under the microscope, might be easily mistaken for 
tubercle or sarcoma tissue. At first the cells are round; at a later stage 
of the inflammation epithelioid and giant cells are formed immediately 
around the fungus. Hoche presents a study of the histogenesis of the 
nodule in typical actinomycosis. The essential points brought out are 
that the ray-fungus, especially when of feeble virulence, provokes an active 



P v rHOLOQI \\ i) MOEB] D an a roMV. 



62'i 



phagocytosis and the establishmenl of an area of inflammation. The 
gradual extension of the disease Is caused by the transportation of the 
mycelial filaments by the phagocytes. The absence of lymph-gland com- 
plications is due to the accumulation of cells about the periphery of the 
focus, and general dissemination occurs only through the invasion of the 
walis of blood-vessels. As the disease is almost always attended by sup- 
puration at some time during its course, it has been customary to ascribe 
to the actinomyces pyogenic properties. Israel has always held that the 
actinomyces is a pus-producing fungus, in opposition to Ponfick and other 
pathologists, who claim thai when suppuration takes place it is the result 
of a secondary infection with pus-microbes. As cases of actinomycosis 
have been recorded in which the disease remained stationary in the granu- 








Fig. 206. Fig . 207. 

Fig. 206.— Actinomycelial Cluster in Giant Cell; Inoculation of Rabbit with the Acid- 
Proof, Atypical Ray-fungus of Finger. (Zeiss 1 / 12 , ocular 4.) (Schulze.) 
Fig. 207.— Giant Cell with Actinomycelioid Cluster. From a renal tubercle fourteen days 
after injection with Moeller's timothy bacillus. (Zeiss V12. ocular 2.) (Lubarsch.) 

lation-stage, for an indefinite period of time, without suppuration taking 
place, and pus-microbes have been cultivated from the pus of actinomy- 
cotic abscesses, it appears more than probable that suppuration occurred 
independently of the presence of the fungus, and was produced by the 
specific action of pus-microbes on the granulation-tissue. Firket asserts 
that the actinomyces does not appear to produce coagulation-necrosis, but, 
from a study of the earliest-formed colonies, he finds that the first effect 
of the fungus is to induce cellular hyperplasia. It is as if the tissue- 
elements resented the intrusion of the parasite, which, however, mostly 
gains the upper hand; so that the result is the formation of granulation- 
tissue and, later, abscesses that characterize the disease. Suppuration 



. 9 PEIXCIPLE5 OF SUEGEET. 

takes place earliest when the disease occupies a location where secondary 
infection with pus-microbes is most liable to occur. As a rule, it may be 
stated that, the earlier suppuration takes place, the more rapid is the 
spread of the disease and the graver the prognosis; while the absence of 
suppuration indicates comparative benignity, and points in the direction 
of a more chronic form of the affection. 

The localized chronic form of actinomycosis resembles, in its clinical 
features and its anatomical locations, more closely sarcoma than any other 
affection, and is most frequently mistaken for this form of malignant 
growth. In such cases it would be difficult, if not impossible, in the ab- 
sence of the specific fungus, to make a differential diagnosis between it 




m 




Fig. 208. — Actinomyces: Section from Actinomycotic Swelling. X 300. (Fliigge.) 

and round-celled sarcoma, even by a most careful microscopical examina- 
tion, as the histological structure of both is almost identical. 

CLINICAL VAEIETTES. 

If infection take place by fully-developed actinomycetes. it can only 
do so by the fungus or its granules gaining entrance into the tissues 
through some loss of continuity in the cutaneous or mucous surface. It 
has been claimed that infection of the intestinal mucous membrane can 
take place by the fungus gaining entrance into a follicle in case the outlet 
of the latter becomes blocked by inflammation, followed by rupture and 
entrance of the essential cause into the tissues. In the cases in which 
no primary infection-atrium could be found, it must be taken for granted 
that the local lesion had healed between the time infection took place 



CLINICAL VARIETIES. 

and the first manifestations of the disease, or that infection was 
by the entrance i - s, which, from their small - . could possibly 
find their way into the tissues through intact mucous surfaces. In refer- 
ence to the primary localization of the disease, Moosbrugger gives the fol- 
lowing statistics: Ir. 31 - the lower jaw, mouth, and throat were 
he upper jaw and cheek; in 1, the tongue; in 2, the 
s >n of the oesophagus; in 11. the intestines; in 14. the bronchial tract 
and the lungs; in T the point of entrance could not be ascertained. In- 
fection may take place through any abraded surface brought in contact 
with the specific cause, and for clinical purposes the cases may be divided 
into the following three groups: 1. Cutaneous surface. 2. Alimentary 
canal. 3. Respiratory tract. 

1. Cutaneous Surface. — A number of well-authenticated cases of 
primary actinomycosis of the skin have been placed on record. Monestie 
states that actinomycosis affecting the skin may be secondary to extensive 
visceral invasion or may be local, as in connection with the inferior max- 
illa. The affection is most common in the face and next on the hands; 
that is, in localities most exposed to direct infection. It manifests itself 
in two forms: the gummatous and the anthracoid, the former presenting 
cavities resembling the gummata of syphilis or of tuberculosis, containing 
pus. each abscess communicating with the surface of the skin through a 
small fistula. The anthracoid variety presents numerous fistula?, which 
discharge a small quantity of pus, and which does not collect at any one 
point. A pathognomonic sign, observed by Derville, is the presence of 
macula? more or less pronounced according to the color of the surround- 
ing skin. If the general color is pale, they are violaceous; if dark, they 
are black or bluish gray. The spots vary in size from a pinhead to a bean, 
and present a central whitish point. Partsch describes a case of actino- 

~:s developing in the scar left after extirpation of the breast. The pa- 
tient was a man aged 60 years. In June, 1SS4, his left breast was removed 
for an ulcerating carcinoma. As the wound did not heal by primary union, 
and the process of cicatrization was very slow, a number of small skin- 
grafts from a perfectly healthy young man were transplanted. The wound 
was practically healed in September. Two months later the cicatrix ulcer- 
ated and an abscess discharged itself. Actinomycetes were found in the 
pus. The parts were excised, and the progress of the disease was ap- 
parently arrested. Xo explanation could be made as to how the infection 
occurred. Hochenegg reported a case of primary actinomycosis of the 
skin in the left submaxillary region. He attributed the disease to an in- 
vasion of the fungus through a small atheroma. 

In Kaposi's case, when the disease was first noticed, it appeared as 
a red spot, the size of a florin, on the left pectoral muscle, which gradu- 



630 PRINCIPLES OF SURGERY. 

ally increased to the size of a walnut and then gradually flattened down 
and disappeared. lEeanwhile, fresh spots and lumps appeared, some as 
large as a pigeon's egg. Eleven years after the beginning of the disease 
a swelling as large as an apple appeared over the spine of the sixth ver- 
tebra, which gradually extended forward and, a year later, formed a large 
tumor behind the right axilla. A year later this swelling had diminished 
in size to that of a pigeon's egg, and then again increased in size. Ulcera- 
tion set in, exposing a fungous, bleeding surface. At this time the entire 
trunk, but not the limbs, was covered with nodules, spots, and stripes. 
The infiltration was located in the corium. This case is remarkable for 
the chronicity of the disease, the multiple points of regional infection, 
and the limitation of secondary infection with pus-microbes to a few iso- 
lated nodules. 

At the meeting of the German Society of Surgeons, in 1889, Leser 
reported 3 cases of primary actinomycosis of the skin that had come 
under his own observation in the course of a single year. In his remarks 
on this subject he placed special stress on the manner in which the dis- 
ease extends. In the periphery of the primary lesion he found numerous 
minute nodules, later becoming the seat of destructive changes, resem- 
bling, in this respect, the clinical features of tuberculosis of the skin. The 
extension of the disease in the direction of the deep tissues takes place by 
the formation of passages corresponding to the size of a lead-pencil; these 
are filled with yellowish-gray or reddish-gray granulations, which attack 
and destroy tissues, irrespective of their anatomical structure. The lym- 
phatic glands were always found intact. Mueller reports two cases of 
actinomycosis of the mammary gland. The fungus was found in the in- 
flammatory product in both cases. The origin is obscure. Each had re- 
ceived a blow upon the breast and in both cases a poultice of linseed meal 
was applied after the incision was made. 

2. Alimentary Canal. — The frequency with which the disease affects 
the mouth and jaws of cattle is explained by the occurrence of numerous 
points of injury caused by masticating rough food, that furnishes the 
necessary infection-atrium through which the fungus invades the tissues. 
In man the disease lias been observed in nearly all parts of the alimentary 
canal. 

Teeth. — In man infection takes place frequently through carious 
teeth, and through abrasions in the gums and mucous membrane of the 
mouth. Israel found the fungus in the cavities of carious teeth, and 
Partsch detected in the same locality almost pure cultures without any 
manifestation of disease except chronic periodontitis. The fungus occurs 
here often side by side with leptothrix. 

Tongue. — Hochenegg saw a case of actinomycosis of the tongue 



i i.i\ [C m. \ \i;m:i [B8. 63] 

caused by an infected carious tooth. The Bwelling was the size of a cherry, 
Located Dear the apex of the organ. The affection had existed for two 
months. The growth was excised, and on examination was found to con- 
Mst o( granulation-tissue, with a central yellow mass the size of a millet- 
seed. Besides this case :> other eases of actinomycosis of the tongue are 
on record: 1 primary, 1 secondary to disease of the jaw, and 1 metastatic. 

Jaws. — 'That carious teeth furnish a frequent infection-atrium in 
maxillary actinomycosis is well known, and in many instances the disease 
in its early Btages lias been mistaken for an ordinary dental affection, and 
patients have often sought relief at the hands of a dentist. The lower 
jaw is most frequently affected, the growth being connected with the bone 
or situated close to it, or it has already extended to the submental or sub- 
maxillary region. The disease often pursues a chronic course, closely 
simulating periosteal sarcoma, until it reaches the loose tissues of the neck, 
when rapid extension takes place, in a downward direction, along the sub- 
cutaneous connective tissue and the intermuscular septa. Israel refers to 
a ease in which the actinomycotic swelling in the submaxillary region ex- 
tended, in five months (August to December), to the level of the thyroid 
cartilage. When the disease is primarily located in the upper jaw, which, 
however, occurs only in exceptional cases, it tends to invade rapidly the 
adjacent soft parts, and even to implicate the base of the skull and the 
brain. The prognosis is always more serious when the disease affects the 
upper than the lower jaw. as the tendency here to invade the deep struct- 
ure is much greater. Two cases of actinomycosis in man have come under 
my observation, and as both of them originated in the mouth, and repre- 
sent, from a prognostic point of view, two distinct classes, I will describe 
them briefly. Since the second edition made its appearance a number of 
cases have come under my observation at the clinic of Eush Medical Col- 
lege, among them two cases of intestinal actinomycosis. 

The first patient was a man 30 years of age, German by birth, and 
a soda-water manufacturer by occupation. His business required him to 
make frequent trips into the country by team. He had no recollection 
of having come in contact with cattle suffering from "swelled head" or 
"lumpy jaw/"' During the winter of 1886 he suffered from what he sup- 
posed was an ordinary cold; the right side of the lower jaw was swollen 
and painful. As one of the molar teeth showed evidences of decay and 
had become loose, it was extracted. The pain and swelling, however, did 
not improve, and the attending physician extracted all of the molar teeth 
of the lower jaw on that side. At this time a fungous mass commenced 
to appear over the surface of the edentulous bone. The cheek on the 
affected side was also greatly swollen. The patient was admitted into the 
hospital about six months after the first symptoms had appeared. At 



632 PRINCIPLES OF SITEGEEY. 

this time the lower jaw, in the mouth, presented a fungous mass extending 
from the angle of the bone to the first bicuspid: the swelling extended 
as far as the tonsil. The cheek was enormously swollen from the an^le of 
the mouth to the lower margin of the parotid gland. The skin over the 
swollen part presented a pale, glossy appearance, and the superficial veins 
were considerably dilated. Around the margin of the swelling no distinct 
border-line could be felt, the infiltrated parts fading gradually into the 
healthy surrounding tissues. Free suppuration from the surface of the 
fungous granulations, and a number of small abscesses had discharged 
themselves into the cavity of the mouth. As some doubt existed as to the 
character of the inflammation, careful and repeated examinations were 
made of the pus removed from the small abscess-cavities, and on several 
occasions fragments of actinomyces were found. The discovery of the 
specific cause of the inflammation cleared up the diagnosis and furnished 
an urgent indication for operative treatment. An incision was made along 
the lower border of the jaw from just below the articulation to near the 
symphysis, and, after arresting all haemorrhage, it was carried into the 
cavity of the mouth. The alveolar processes of the jaw were affected, and 
were removed with chisel and cutting-forceps. Wherever the periosteum 
showed signs of infiltration it was carefully scraped away, and finally the 
whole bone-surface was thoroughly cauterized. The infiltrated soft tissues 
were dissected out with knife and scissors: the disease was found to have 
extended as far as the tonsil. The bottom of the wound was iodoformized 
and packed with iodoform gauze, while the external wound was sutured. 
The entire external wound healed by primary union, and the cavity in the 
mouth closed slowly by granulation. The patient's general health con- 
tinued to improve rapidly, until six weeks after the operation, when the 
neck below the scar became swollen, followed in a short time by the forma- 
tion of abscesses reaching from the angle of the jaw to the clavicle, and 
posteriorly as far as the spine of the scapula. Xumerous openings were 
made and efficient drainage established, but suppuration continued un- 
abated, and the patient became extremely emaciated. The suppurative 
inflammation extended, and four months after the first operation the pa- 
tient died; the symptoms during the last days of life pointed to an hypo- 
static pneumonia. Actinomycetes were constantly found in the pus dur- 
ing the entire course of the disease. I believe that the recurrence of the 
disease was due to imperfect removal of infected tissues in the posterior 
and lower portion of the pharynx. 

The second case came under my care during the summer of 1887. 
The patient was a young man. employed on a farm. About five months 
before he was admitted into the hospital he had a number of teeth ex- 
tracted from the right upper jaw, under the belief that the teeth, some of 



CLIN [C LI \ LBIETIES. 633 

which won' decayed, were the cause of the pain and swelling in that region. 
The physician in attendance diagnosed sarcoma of the upper jaw, and 
Bent the case to me for operation. On my first examination, I found a 

swelling involving the right side of the face, extending from the zygo- 
ma tie arch to near the lower border of the lower jaw, involving the deep 
tissues, and connected with the alveolar processses of the posterior portion 
of the tipper jaw. The swelling was firm and without well-defined mar- 
gins. No evidences of suppuration. The history of the case, and particu- 
larly the location, extent, and physical properties of the swelling, led me 
to the opinion that it was the result of actinomycotic infection. All in- 
fected tissue was thoroughly excised through a large external incision, the 
jaw-bone scraped and cauterized. The entire thickness of the cheek, with 
the exception of the skin and superficial fascia, appeared to be transformed 
into granulation-tissue. In the granulations numerous minute yellowish- 
gray bodies were found, which, under the microscope, showed the typical 
structure of the ray-fungus. The mycelia were not so bulbous as we find 
them pictured in the books, but the distal extremity appeared to be sur- 
rounded by dust-like bodies, presenting the appearance of a small brush. 
These minute granules I regarded as spores. In the first case, in which 
suppuration had taken place, I never succeeded in finding the actino- 
myces perfect and complete; in the second case the granulation-tissue had 
not been destroyed by suppuration, and the fungus was found in a perfect 
condition and in a state of fructification. These cases present a striking 
contrast, both in regard to the local condition and the ultimate termina- 
tion. In the first case secondary infection with pus-microbes had already 
taken place, and the phlegmonous inflammation that followed this occur- 
rence prepared the tissues again for the diffusion of the actinomycotic 
process; while in the second case the inflammatory process had not passed 
beyond the granulating stage, and the boundary-line between healthy and 
diseased tissue was also more distinctly marked: a most important factor 
in the operative treatment. The first patient died from recurrence of the 
disease in the vicinity of the operation wound and its extension to the neck 
and chest; while in the second case the wound healed, and the patient has 
remained in perfect health since. 

3. Intestinal Canal. — In primary intestinal actinomycosis the disease 
is caused by ingress of the fungus with food or water, and its implanta- 
tion upon the mucous surface. At the point of implantation the fungus 
multiplies, and by its growth invades the submucous tissue, which becomes 
the seat of active tissue-proliferation. Arrest and implantation of the 
actinomycetes are determined by antecedent pathological changes. Chiari 
has given an excellent account of the pathological condition found in a 
case of intestinal actinomycosis that came under his observation. The 



634 PRINCIPLES OF SURGERY. 

patient was a man, 36 years of age, who during life presented, as the most 
prominent clinical feature, progressive marasmus. At the necropsy 
chronic tuberculosis in the apices of the lungs and a few tubercular ulcer- 
ations in the lower portion of the ileum were found. The large intestine 
presented a very remarkable appearance, the mucous membrane of which, 
except the caecum and ascending colon, was covered with whitish deposits, 
forming round and oblong patches, some of them 1 cubic centimetre in 
diameter and 5 millimetres in thickness. In some of these patches could 
be seen minute yellowish-brown and yellowish-green granules. The 
patches were firmly adherent, and when removed left a loss of substance 
in the mucous membrane. The mucous membrane throughout was in a 
state of catarrhal inflammation. On microscopical examination the gran- 
ules proved to be actinomycetes. The mycelium had penetrated into the 
tubular glands and showed calcified, club-shaped conidia. The calcifica- 
tion of the club-shaped extremities had undoubtedly prevented deeper 
penetration of the fungus. Hochenegg presented a case of actinomycosis 
to the Medical Society of Vienna in a man, 43 years of age, who had sus- 
tained an injury of the abdomen nine months previously, and had since 
that time noticed a painful swelling at the seat of injury. In the region of 
the umbilicus a fistulous opening formed, which continued to discharge a 
thin secretion, in which the actinomyces was constantly found. The patient 
was very much emaciated and many of the teeth were carious. There was 
no swelling about the jaws or neck. Examination of the organs of the 
chest and the sputum revealed no additional diagnostic information. The 
author expressed the opinion that the inflammatory swelling caused by the 
contusion furnished the necessary conditions for the localization of the 
actinomyces from the intestinal canal. 

Zemann reports 5 cases of actinomycosis of the abdomen. In 4 of 
them the disease commenced with sharp, lancinating pains in the abdo- 
men, and during their course presented the clinical picture of chronic 
peritonitis. Swellings could be found in one or more places in the an- 
terior abdominal wall, and the abscesses were either incised or opened 
spontaneously, and in 3 cases they communicated with the intestinal 
canal. The first case was a woman, 30 years of age, who had a fistulous 
opening in the anterior abdominal wall which communicated with a swell- 
ing in the left parametrium. The patient stated that this SAvelling ap- 
peared soon after her last childbed. A constant discharge of yellowish-red 
pus was maintained, in which, under the microscope, numerous actino- 
myces could be seen. The patient died of exhaustion, and at the post- 
mortem chronic para- and peri- metritis were found, with extensive pus- 
cavities that communicated with the rectum and bladder. The second 
case occurred in a person, 18 years of age, who, during life, had suffered 



CLINICAL \ LRIBTIES. G35 

from a Large abscess in the abdominal cavity, under the right lobe of the 
liver, which communicated with the intestinal canal, and had led to 
numerous fistulous openings in the anterior abdominal wall. 

At the necropsy a loop of the ileum was found perforated and in 
communication with the abscess-cavity. The pus contained numerous 
actinomycetes. In the third case the diagnosis was made post-mortem by 
the discovery of the actinomyces in the pus. The disease was located in the 
lower portion of the ileum and caecum, where it had caused suppuration 
and numerous adhesions. A most remarkable and interesting history 
is connected with the fourth case. A robust, well-nourished woman, 40 
years of age, was attacked quite suddenly with pain in the stomach, high 
temperature, diarrhoea, and vomiting, followed by cerebral symptoms and 
death. At the necropsy the right Fallopian tube was found transformed 
into a large abscess, both extremities of the tube closed, and walls of sac 
lined with granulations containing the actinomyces. The fifth patient was 
50 years of age, and had suffered for a long time from lancinating pain 
in the abdomen; a fistulous opening formed in the umbilical region and 
discharged a thin, yellowish-green pus. The post-mortem showed actino- 
mycosis of the peritoneum, small intestine, left ovary, and liver; large 
abscess among the intestinal coils; perforation of small intestine and 
bladder. In the upper part of the small intestine small pigmented cica- 
trices were found. In all of the above cases the microscopical examina- 
tion revealed the presence of the fungus in the granulation-tissue as well 
as in the pus of the abscess-cavities. In a case of intestinal actinomycosis 
reported by Langhans, the disease started evidently from the appendix 
vermiformis, 4 centimetres in length, the end of which appeared as if 
transversely cut in an abscess-cavity the size of a walnut. The abscess 
was on the right side of the bladder, and so deep in the pelvis that during 
life it could not be located. The abscess pursued a chronic course, and 
the walls were well defined; no signs of chronic or acute peritonitis. 
Furthermore, the mucous membrane of the appendix was studded with 
cicatrices, and presented a slate color. The principal seat of the actino- 
mycotic process was in the liver. In a second case reported by the same 
author the clinical course of the disease resembled perityphlitic abscess. 
The necropsy showed perforation of the caecum and ascending colon. ISTo 
cicatrices in the mucous membrane or surrounding tissues. In all prob- 
ability, the perforations occurred from without inward. 

Luening and Hamm have reported, with interesting details, a case 
of primary actinomycosis of the colon with metastatic deposits in the 
liver. The patient was a man 28 years of age, who, in 1880, suffered from 
an acute abdominal affection, which at the time was diagnosed as typhlitis. 
Four years later a second attack occurred, attended by symptoms of 



636 PEINCIPLES OF SUEGEEY. 

intestinal obstruction. Patient was very ill for eight days, when the 
symptoms of obstruction subsided, and he made a slow recovery. During 
the year 1887 he had a third attack, attended by high fever and absolute 
constipation for eight to ten days. During the month of December of 
the same year he had another, but less severe, attack, and at this time 
a hard swelling made its appearance in the right side of the abdomen. 
From this time until he was admitted into the hospital, April 5, 1888, 
he was confined to bed. The patient was at this time greatly emaciated, 
with a temperature of from 38.4° C. to 39.8° C. Swelling the size of a 
fist in the right side of the abdomen, half-way between umbilicus and 
anterior superior spine of the ileum. Externally this swelling presented 
redness and oedema. Fluctuation indistinct. Deep palpation showed that 
the swelling extended to right hypochondrium; abdomen not tympanitic. 
Swelling painful and tender, pain extending to spermatic cord and testicle 
on same side. A few days later abscess was incised, and nearly a quart 
of brownish pus, having a faecal odor, escaped. Digital exploration re- 
vealed an irregular cavity, whose walls at some points were plainly lined 
with intestinal coils. Disinfection and drainage. As the symptoms did 
not improve materially, the abscess-cavity was again scraped out and dis- 
infected four weeks later. After the second operation it was noticed 
that the pus contained yellow granules, which, under the microscope, were 
shown to be actinomyces. The abscess was incised a third time, but the 
patient kept losing ground, and died October 9th. The autopsy revealed 
primary actinomycosis of the ascending colon, with multiple fistulous 
perforations. A metastatic actinomycotic abscess of the liver had per- 
forated into the hepatic vein, resulting in multiple metastases in the lungs. 
The cases of intestinal actinomycosis reported above warrant the opinion 
that the mucous membrane of the intestinal canal is frequently the seat of 
primary localization of the actinomyces, thus corroborating the state- 
ments of Johne in reference to this disease in animals. 

BEOXCHIAL TUBES AXD LUNGS. 

If an actinomyces should be inhaled with the inspired air, and 
should become implanted upon the bronchial mucous membrane, and 
find favorable conditions for its growth, the granule will become sur- 
rounded by new cells derived from the preexisting epithelial cells, and 
thus become the centre of a minute granuloma. 

By multiplication of the actinomyces new nodules are produced, 
around each of which the preexisting tissue is transformed into embryonal 
tissue, which in time is destroyed, resulting in suppuration and loss of 
tissue. Israel reported a case of actinomycotic abscess of the lung caused 
by the entrance of an infected tooth into the air-passages. In this in- 



BRONCHIAL TIBKS \\1> l.i \(iS. 



G37 



stance the fungus was conveyed into the bronchial tube with the carious 
tooth, and the infected foreign body became the centre of the specific 
inflammation. 

Oases of primary actinomycosis of the lungs, however, have been 
observed where no such direct carrier of the contagium could be found, 
and in which infection must have occurred by the direct inhalation of 
the fungus or its spores with the inspired air. Szenasy found, in the 
case of the wife of a butcher, who had suffered for nine years from 
severe pain in the right side of the chest, latterly attended by a severe 
cough, in the right mammary region, a fluctuating swelling, the size of a 
hen's egg, covered with normal skin. On the outer side of this swelling, 
in the intercostal space between the third and fourth ribs, another swell- 
ing existed, double in size and elongated in shape, and with indistinct 
margins. This latter swelling had been noticed for nine years, and was 
tender to the touch. Auscultation over the fourth and fifth intercostal 




Fig. 209. — Actinomyces from Lung of Cow; Fungus in the Centre of Inflammatory- 
Product. A, normal epithelial cells of bronchus attached to connective tissue; B, large 
epithelioid cells; C, leucocytes. X 350. (Marchand.) 



spaces on the healthy side revealed bronchial breathing and diffuse bron- 
chial rales. Temperature, 38.4° C. (101.1° F.). The urine contained a 
trace of albumen. By aspiration 150 cubic centimetres of thick, yellow 
pus were removed, and contained colonies of the actinomyces. Actinomyces 
were also found in the sputum. The patient had carious teeth, but no 
signs of actinomycosis could be detected in the mouth. 

Canali relates the clinical history of a girl, 15 years of age, who 
had suffered for eight years from a cough, attended by a scanty, fetid 
expectoration. Inspection and percussion yielded only negative results. 
Auscultatory symptoms pointed to a diffuse catarrh. Under the micro- 
scope the sputum was seen to contain pus-corpuscles, epithelial cells, and 
numerous actinomycetes. Xo primary source of infection could be found 
in the mouth, pharynx, or nose. 

Moosbrugger interprets the mechanism of the ingress of the actinomyces 



G38 PRINCIPLES OF SURGERY. 

by assuming that the fungus enters the bronchial tubes during inspiration, 
and becomes at first deposited upon the mucous membrane, where its 
presence and growth cause a destruction of the epithelial cells, when it 
reaches the submucous and peribronchial tissues, in which a nodule of 
granulation-tissue is produced that by pressure induces degenerative 
changes and gradual destruction of the bronchial wall for further infec- 
tion. He believes that the peribronchial lymphatic vessels and glands 
take an active part in the local diffusion of the process, as they furnish 
an avenue for the dissemination of the fungus or its spores. He claims 
the existence of an actinomycotic lymphangitis, but confesses that he 
has never seen the fungus inside of lymphatic vessels. As soon as the 
fungus reaches the pulmonary tissues, it gives rise to parenchymatous in- 
flammation, the first product of which is always granulatiomtissue, which, at 
a later stage, and under the influence of a secondary infection with pus- 
microbes, undergoes transformation into pus-corpuscles and the formation 
of abscesses. 

ACTINOMYCOSIS OF BRAIN. 

Bollinger placed on record the first case of primary actinomycosis of 
the brain. The patient was 26 years of age. The intra vitam diagnosis 
was tumor of the brain; the most prominent symptoms were severe head- 
ache, paralysis of left abducens, congestion of optic papilla, and mo- 
mentary unconsciousness. The swelling in the brain, found on autopsy, 
presented the characteristic features of a cystomyxoma in the third 
ventricle; all of the ventricles were found considerably dilated. The swell- 
ing contained numerous colonies of the fungus in all possible stages of 
development. The tendency to suppuration of the tissues, usually found 
in all cases of actinomycosis in man, was entirely absent in this case. 
This case, if any, appears to be one of cryptogenetic infection, as the 
fungus or spores must have entered somewhere through the cutaneous or 
mucous surface without producing the disease at the primary portio in- 
msionis, and, localizing in the brain by embolism, resulted in primary 
actinomycosis in this organ. 

Keller reported a case of metastatic actinomycosis of the brain in 
which a correct diagnosis was made during life. The patient was a 
middle-aged woman, who suffered from pleurisy, and six months there- 
after an abscess developed over the cartilages of the sixth and eleventh 
ribs, in the pus of which actinomyces were found. Two years later in- 
creasing paresis of left arm developed, followed by convulsions, confined 
at first to the arm, then becoming general, and at times identical with 
cortical epilepsy. Diagnosis of actinomycosis affecting the motor area was 
made; operation was suggested and declined. The paresis extended to 



s\ M PTOMS vn i) DIAGNOSIS. 639 

left lower extremity and Lefl side of Eace; Later, convulsions, headache, 
vomiting, and loss of consciousness, soon deepening into coma. Jmrger 
then obtained consenl to operate. The patienl was moribund, and re- 
quired do anaesthetic. Ee exposed the right ascending parietal convolu- 
tion, incised the dura mater and the discolored brain-surface, and removed 
2 ounces of thin, greenish pus. in w r hich were found actinomycetes in great 
abundance. When the pus was evacuated, she recovered from the deep 
coma, and. while still on the operating-table, called for water. On the 
following day consciousness returned, and on the eighth the facial paral- 
ysis disappeared. In two months the wound had healed and the paralytic 
Lesions improved, but there remained some paresis of left arm, with con- 
traction of the fingers. In less than one year there v r as a recurrence of 
the symptoms, and Burger reopened the brain-abscess, followed by the 
escape of a considerable quantity of pus. No material improvement fol- 
lowed, and the patient died a few days thereafter. 

At the post-mortem, the middle third of the right frontal and parietal 
convolutions was occupied by a large mass of newly-formed tissue, pro- 
truding over the surface* and reaching into the substance of the brain 
for one inch. Underneath it, deeply buried in the white substance, an 
unopened, capsulated abscess, the size of a nutmeg, was discovered. 

SYMPTOMS AND DIAGNOSIS. 

Actinomycosis is an inflammatory disease that clinically is noted for 
its chronicity. The specific product, composed of granulation-tissue, is 
abundant, and the swelling, often of considerable size, resembles more a 
tumor than an inflammatory swelling. The extension of the morbid 
process takes place by diffusion of the ray-fungus in loco, in preference 
along the loose connective-tissue spaces, each fungus constituting a 
nucleus for a nodule of granulation-tissue. By confluence of many such 
nodules the inflammatory swelling often attains a very large size, and 
when suppuration occurs in the interior the further history is that of 
chronic abscess. Eegional dissemination of the infective process never 
takes place through the lymphatic glands. When the lymphatic struct- 
ures become implicated, it is an indication that secondary infection has 
taken place. In exceptional cases the disease pursues quite a rapid course, 
and may then be mistaken for an acute phlegmonous inflammation, osteo- 
myelitis, or, when diffused over a large surface of the body, for syphilis. 
A good illustration of the former class is furnished by the case reported 
by Kapper. A soldier, 22 years of age, became suddenly ill with febrile 
symptoms and a rapidly-increasing swelling of the lower jaw. An early 
incision was made and liberated a large quantity of pus, which, on micro- 
scopical examination, w T as found to contain the actinomyces. It is interesting 



640 PRINCIPLES OF SURGERY. 

to note that in this case the various teeth from where the infection had 
evidently taken place contained threads of leptothrix and the actinomyces. 

At a meeting of the Berlin Medical Society, about ten years ago, 0. 
Israel gave an accurate description of the post-mortem appearances of 
a case of diffuse actinomycosis. The patient, a woman 44 years of age, 
had been treated for syphilis in one of the surgical clinics. The heart 
contained a number of minute abscesses containing the fungus in large 
numbers. A large abscess between the diaphragm, stomach, and spleen 
contained thick pus of a greenish color, — an unusual occurrence in cases 
of actinomycosis, — but no fungi. The spleen was the seat of large and 
numerous minute abscesses, and the liver and kidneys also contained small 
abscesses, and in all of them actinomyces were found. Israel claims that 
this case affords a good illustration of his view that the actinomyces, 
as regards its effect on the tissues, occupies a position half-way between 
the bacillus of tuberculosis, which produces only granulation-tissue, and 
the pus-microbes, which produce pus. It was impossible in this case, as 
in so many others in which multiple deposits have been found, to locate 
with accuracy the primary seat of infection. The teeth were perfect and 
the whole digestive tract showed no evidence of disease. Metastasis in 
actinomycosis takes place in the same manner as in pyaemia and malig- 
nant tumors. At the primary seat of infection the fungus or its spores gain 
entrance through a defective vein-wall into the general circulation, and, at 
the point of arrest in a distant capillary vessel, establish an independent 
centre of infection, with all the pathological attributes of the primary infec- 
tion. General infection is of rare occurrence in actinomycosis, as this 
disease is noted for its tendency to extend locally, where it often results 
in extensive regional dissemination and destruction of tissue. Actinomy- 
cosis resembles, in its clinical behavior, very closely the malignant tumors, 
in that it will invade every tissue with which it comes in contact, irre- 
spective of its anatomical structure. Primary localization is very apt 
to occur in the connective tissue, and in preference it extends along this 
structure; but periosteum, bone, muscles, tendons, cartilage, — in fact, all 
of the tissues of the body, — succumb to the fungus as quickly as they be- 
come infected. 

In actinomycosis of the jaws and the vertebras we often find extensive 
destruction of bone, with large abscesses communicating with the primary 
lesion. Before suppuration takes place the actinomycotic swelling is quite 
firm on pressure, and, if the disease extend rapidly, it is surrounded by a 
diffuse oedema. Pain and tenderness are usually never severe, and often 
almost wanting. Bedness appears as soon as the infection has extended 
to the skin. Suppuration usually develops in consequence of direct infec- 
tion with pus-microbes through some minute surface defect in the swell- 



>\ MITO.MS AMI DIAGNOSIS. 6 I 1 

ks Boon as Buppuration sets in, the swelling not only increases 
rapidly in size, but regional diffusion is hastened by the breaking down 
of the granulation-tissue thai before held the fungi fixed in their re- 
spective localities. The same tendency to migration of an actinomycotic 
3 observed as in tubercular abscess. The characteristic feature 
of actinomycotic pus is the presence of minute, macroscopical, yellowish 
granules; the actinomyces, on careful inspection, can almost always be 
ered. If these granules are placed under the microscope their char- 
acteristic structure will at once become apparent. 

The differentiation between actinomycosis and syphilitic gummata 
requires the greatest care, and as both affections are benefited by the ad- 
ministration of potassic iodide the therapeutic effect of this drug does not 
serve as a diagnostic criterion. Evidences of tertiary syphilis in other 
parts of the body must be looked for and taken into careful consideration 
in formulating a diagnosis. 

In cases of actinomycosis of any of the internal organs, attended by 
suppuration and discharge of pus through some one of the outlets of the 
body, the diagnosis will usually depend almost exclusively upon the de- 
tection of the fungus in the discharges. Microscopical examination of 
the sputum and faecal discharges, in cases of suspected actinomycosis of 
the lungs or the intestines, is the only positive means of making a differ- 
ential diagnosis between these affections and pulmonary and intestinal 
tuberculosis. Actinomycosis of the skin, mouth, tongue, and jaws might 
be mistaken for sarcoma, carcinoma, tuberculosis, and syphilis. As, with 
the exception of carcinoma, all of these affections present under the 
microscope an histological structure that it would be often difficult to 
identify microscopically, the differential diagnosis by means of the micro- 
scope must rest on the detection of the ray-fungus imbedded in the 
granulation-tissue. Sarcoma does not suppurate or break down as early 
as the actinomycotic or tubercular swelling. Carcinoma primarily starts 
in the epiblast or hypoblast, and, even during the earliest period of the 
growth, there is no difficulty in demonstrating an intimate relationship 
between the skin or mucous membrane and the tumor encroaching upon 
the mesoblast. In actinomycosis tissue-proliferation takes place around 
each fungus in the mesoblast, and the skin or mucous membrane is in- 
fected and destroyed from within outward. In tuberculosis regional in- 
fection almost always occurs through the medium of the lymphatic vessels 
and glands, while these structures are seldom or never invaded in actino- 
mycosis. In the absence of microscopical proof of the nature of the lesion, 
it may become necessary to resort to a therapeutic test in differentiating 
between syphilis and actinomycosis. Large doses of potassic iodide, ad- 
ministered four times a day, will have a decided effect in reducing the 



642 PRINCIPLES OF SURGERY. 

size of a gumma in the course of two or three weeks, while no such prompt 
result will be obtained if the lesion is of an actinomycotic nature. 

PROGNOSIS. 

Actinomycosis is a more dangerous affection than tuberculosis. While 
a spontaneous cure not infrequently takes place in the latter, we have 
no proof that actinomycosis ever terminates in such a satisfactory manner 
without the surgeon's aid. Actinomycosis of the internal organs proves 
fatal almost without exception on account of the inaccessibility of the 
disease to radical surgical treatment. In such cases numerous fistulous 
openings form, discharging profuse quantities of pus, and the patient 
dies in from one to two or three years from exhaustion or amyloid de- 
generation of the internal organs. If the disease is located in external 
parts, local extension often takes place very slowly until suppuration sets 
in, when the actinomycotic abscess migrates from place to place, attacking 
all the tissues that come in its way, and life is finally destroyed by pyaemia, 
sepsis, or exhaustion. The prognosis is always favorable when the disease 
is recognized early, and when it is located in parts accessible to a radical 
operation. As metastasis is of rare occurrence in actinomycosis, complete 
removal of the primary focus is followed by a permanent cure. The 
prognosis of actinomycosis in all its forms and in all parts of the body 
has been made much more favorable since it has been shown that the 
potassic iodide possesses decided curative properties in the treatment of 
this disease. 

TREATMENT. 

Thomassen and Nocard first called attention to the value of the in- 
ternal administration of potassic iodide in the treatment of actinomy- 
cosis in animals. Soon after the publication of their results of this method 
of treatment Van Iterson resorted to the use of the same remedy in 
the treatment of the same disease in man with an equally satisfactory 
result. Buzzi and Galli-Valerio have also reported a successful case. In 
this case the disease affected the whole right side of the face, from the 
temple to the clavicle. Large doses of the drug were administred, with 
the effect of promptly diminishing the profuse suppuration, followed ulti- 
mately by a complete cure without further surgical intervention. Eydygier 
reports two cases successfully treated by parenchymatous injections of 
potassic iodide. A case of actinomycosis far advanced and involving the 
lower jaw, the left side of the face, with numerous abscesses about the 
external ear and in the parotid and submaxillary regions, came recently 
under my care in the clinic of Eush Medical College. Owing to the ex- 
tent of the disease, a radical operation was out of question. The patient 



ti;katmi:\ r. 6 !•') 

. man 35 years of age. The treatment was commenced by admin- 
istering 15 grain- of the potassic iodide four times a day and the sinuses 
washed out with a strong solution of the same drug. This treatment 
ontinued until intoxication was produced and the forehead and face 
thickly studded by acne pustules. As in the course of three months 
no decided improvement could be noted, I decided to continue the remedy 
in the same doses and resorted, besides, to its use by cataphoresis. A 15- 
per-eent. solution was used for this purpose and daily sittings for fifteen 
minutes. A marked improvement was apparent in less than two weeks. 
This combined treatment was continued for nearly four months, when the 
patient left the hospital in perfect health. Xo indications of recurrence 
four months after the treatment was suspended. This case has satisfied 
me that cataphoresis is an important aid in the administration of potassic 
iodide in the treatment of actinomycosis. It appears that this remedy 
ves a thorough trial in all cases prior to resorting to the knife and 
more especially in cases in which the disease is so extensive as to preclude 
the possibility of complete removal by local measures. 

Other forms of general treatment in actinomycoses are of no avail, 
and all local measures, short of complete removal of the infected tissues, 
result in more harm than good, as they often give rise to secondary in- 
fection with pus-microbes, which always aggravates the local conditions 
and hastens a fatal termination. In cases where a radical operation is 
out of question on account of the extent of the disease or the importance 
of organs involved in the process, parenchymatous injections of potassic 
iodide or a 2-per-cent. solution of boric acid, a l-to-1000 solution of cor- 
rosive sublimate, or a l-to-1500 solution of nitrate of silver might be tried; 
but, on the whole, such injections have little influence in arresting the 
local extension of the disease. Kottnitz recommends very highly cauteriza- 
tion with solid stick of nitrate of silver in actinomycosis of the skin and 
soft parts in which suppuration and formation of fistulous tracts have 
taken place. He reports four cases of actinomycosis of the head and neck 
treated successfully by the use of this remedy. Dr. HcGovern, of "Wis- 
consin, also reports a successful case. It appears that this caustic pos- 
sesses a specific destructive action on the actinomycosis. The surgical 
treatment of actinomycosis, before suppuration has occurred, consists in 
the excision of the infected tissues in all cases where such a procedure is 
practicable. The incision should be carried some distance, at least 1 / 2 to 
1 inch, from the visible granulations, with a view of removing not only 
the inflammatory tissue, but also the minute invisible foci in its imme- 
diate vicinity. If, after the excision, suspicious tissue is found in the 
wound, this should be removed by a careful dissection with forceps, knife, 
and scissors, or destroyed by using the actual cautery. Acids and other 



644 PRINCIPLES OF SURGERY. 

chemical caustics should not be relied upon in destroying the infected 
tissues. An actinomycotic abscess should be treated on the same prin- 
ciples as a tubercular abscess. The abscess-cavity is freely exposed by 
laying open the fistulous openings, and the granulation-tissue is removed 
with a sharp spoon. Undermined skin is cut away with scissors. If the 
disease has extended to bone, this is also thoroughly scraped, and it 
is a good plan, after the cavity has been thoroughly irrigated and dried, 
to cauterize the whole surface with the actual cautery. Such wounds 
should not be sutured, but packed with iodoform gauze, in order to keep 
the infected area readily accessible to inspection, so as to enable the sur- 
geon at each dressing to recognize a local recurrence. Should this occur, 
the same means are to be repeated in eliminating the infected tissues. 
As soon as the wound is covered with healthy granulations it may be 
closed by secondary suturing, or, if this cannot be done on account of too 
great loss of skin-tissue, the defect is covered with large skin-grafts ac- 
cording to Thiersch's method. Eepeated scraping operations will often 
succeed in finally eradicating the disease, provided the infected parts are 
accessible to vigorous curetting and the application of the actual cautery. 



rllAl'TKK XXV. 



Blastomycetic Dermatitis. 



BLASTOMTCETIC dermatitis, skin-blastomycosis, pseudolupus vulgaris, 
saccharomycosis hominis, and pseudoepithelioma with blastomycetes are 
terms which have been used to signify a chronic parasitic inflammation 
of the skin: an affection which has only recently been recognized and 
subjected to scientific investigation. Of these designations, the first is 
best calculated to indicate the anatomical location, the parasitic nature, 
and pathological character of the disease. This affection was first recog- 
nized in the lower animals (the horse) by Tokishige, a Japanese investi- 
gator, in 1893. He found in the diseased tissues a yeast-fungus, an 
oidium, the etiological significance of which he established later. The fol- 
lowing year appeared the account of the disease as it occurs in man, based 
on clinical observations and careful microscopical and bacteriological in- 
vestigations by Gilchrist and Stokes, of this country, and Busse, of Ger- 
many. In 1899 Hektoen could find only four well-authenticated recorded 
cases, and among these was one case which came under my own treatment 
in the clinic of Bush Medical College and which, at the time, was diagnosti- 
cated as tuberculosis of the skin. This case was fully described by Mr. 
H. G. "Wells, then a senior student and assistant in the surgical clinic. 
Under the direction of Professor Hektoen he made a careful study of the 
specimen in the Pathological Laboratory, which resulted in correct identi- 
fication of the disease and an excellent description of its pathological and 
bacteriological aspects. 

"The patient was brought to the clinic by Dr. J. T. Phillips, of West 
Union, Iowa, on March 23, 1897. Dr. Phillips had observed the case for 
over a year, and furnishes the following history: The patient is a well- 
nourished man, 40 years of age, a native of Iowa, farmer by occupation. 
He presents a good personal and family history, married, has five healthy 
children, none of whom have ever had any similar affection, nor has any 
person of his acquaintance. A thorough physical examination shows him 
to be free from any pulmonary or glandular involvement. The disease 
began eleven years ago as a small pimple on the back of the first phalanx 
of the left little finger. This pimple became an ulcer, which gradually 
enlarged, extending up over the knuckle on to the back of the hand, over 
which it slowly spread. It never invaded the palm. The highest it ever 
reached was just above the head of the radius. It extended from the 
junction of the palm and dorsum of the hand on the ulnar side of the 

(645) 



646 



PRINCIPLES OF SURGERY. 



base of the thumb, and grew down to the second phalanx of the index 
finger, to the middle of the second phalanx of the second finger, just be- 
yond the first phalanx of the ring-finger, and never extended below its 
starting-point on the little finger. During its progress the older portions 
of the lesion would sometimes heal up, leaving a poor substitute for skin, 
which was of low-resisting power, for it would repeatedy become reinvaded 
by the disease. 

"In appearance it was a raised, fungating mass, in some places three- 
quarters of an inch above the normal level of the skin. When washed 




Fig. 210.— A Miliary Abscess in the Epithelium of the Hand, containing in its Upper 
Half a Group of Three Organisms. X 220. (After Hektoen, Journal of Experimental 
Medicine.) 



it was of a dark, cherry-red color, sprinkled with cheesy, pinhead-sized 
masses. After being left for a time the surface would become covered with 
a crust of pus, scales, and debris, which was readily removed. Secondary 
infection frequently occurred, sometimes producing large-sized abscesses. 
When the wet dressings that had been applied for some time were re- 
moved, the growth had a honey-combed appearance and bled very easily. 
Every ordinary form of antiseptic treatment, hot fomentations, etc., were 
tried, but the only evident effect was on the secondary infection. Early 



i;i LSTOMl CE CIC DERM \TI dS. 



G47 



in ii> course attempts bad been made at its removal by caustics, plasters, 
etc., « it h on t result. 

••rain was constant in the hand, often especially severe at night, but 
the patient was able to do his farm-work and felt perfectly well otherwise 
during all this time. Although there were abundant opportunities for in- 
fection of other parts of the body, no other foci ever appeared, and the 
growth was solely by extension. Dr. Phillips considered it a case of skin 
tuberculosis, and Professor Senn agreed to the diagnosis. He removed 
the entire area involved, covering the surface by a plastic operation, with 







**> 







tjrr 







Fig. 211.— The Three Organisms More Highly Magnified. X 1500. {After Eektoen, 
Journal of Experimental Medicine.) 

excellent results. Since his discharge from the hospital the patient has 
been perfectly well, and there have been no recurrences." 

At that time there was very little known concerning blastomycosis 
of the skin, and the macroscopical appearances resembled tuberculosis so 
closely that the error in diagnosis was excusable, so much more so as the 
radical operation, notwithstanding the extent of the disease, proved emi- 
nently satisfactory, both in eliminating the disease permanently and in 
yielding an ideal functional result. The skin with which the dorsum of 
the hand was covered was taken from the anterior surface of the chest 
by making two vertical incisions, elevating the flap and suturing it above and 



648 PRINCIPLES OF SUBGEBY. 

below to the margins of the dorsal wound. After two weeks the parts were 
firmly united and the flap was detached. Since that time four additional 
cases of blastomycetic dermatitis have been reported by physicians of 
Chicago. The one recorded by Anthony and Herzog is of special interest, 
as they showed that the parasitic disease was ingrafted upon a syphilitic 
lesion, and the one by Coates demonstrating that it is clinically and 
histologically an epithelioma. (Fig. 210.) The one reported by Hyde, 
Hektoen, and Bevan proved the value of the therapeutic action of potassic 
iodide. (Fig. 211.) It remains an open question whether or not this 
case was complicated by syphilis. 

THE FUNGUS OF BLASTOMYCETIC DEEMATITIS. 

Hektoen has made a special study of the morphology of this strange 
and as yet imperfectly known parasite. The size, shape, and structure of 



Fig. 212. — An Epithelial Pearl in the Centre of which are seen Budding Forms Sur- 
rounded by Granular Debris. (After Coates.) 

the organism as it grows upon artificial nutrient media vary somewhat. 
Fresh specimens mounted in salt solution, from the culture of glycerin- 
agar, show a highly-refractive organism with a doubly-contoured envelope. 
The fungus resists the action of caustic potash. It stains readily with the 
common aniline solutions, but the stain is rather deep and in many cases 
too diffuse, and the clearest pictures are obtained by a rather prolonged 
staining — fifteen to thirty minutes — of carefully-made films in 0.5-per- 
cent, solution of metlrylene-blue and then washing well with water. The 



Tin: FUNGUS OF BLASTOMYCETH DEBMATITI8. 649 

films are made by suspending a small quantity of the culture in a drop of 
physiological salt solution or of distilled water and drying. 

Large bodies are not as constant in cultures as in the infected tissues 
of the human skin or infected animals. The cell membrane is separated 
from the cell-protoplasm proper by a clear and transparent zone. (Fig. 
812.) 

The form of the parasite is round or oval, sometimes polygonal on 
account of mutual pressure. Budding forms are very frequent and occur 
in all stages of development. The process of budding appears to begin 
with the formation of a small projection of the endosporium, which pushes 
the transparent zone and outer membrane in front of it. Very soon these 




Fig. 213. — Vacuolated and Solid Diffusely-Stained Organisms from Glycerin-agar 
Piilfiirp ( After HektnenA 



Culture. (After Hektoen.) 

layers inclose the new bud fully and the point of attachment to the 
mother-cell may be either flattened or, later, drawn out into a slender 
pedicle. In well-developed bodies the endosporium is vacuolated, and of 
varying size, and deeply stained, sometimes producing appearances that 
resemble the presence of a nucleus, but this is not constant. "With 
age the size of the bodies in the culture gradually increases, and the 
granules are then either crowded to one side or become arranged as a rim 
around the vacuole and the transparent zone becomes indistinct or disap- 
pears altogether. Large bodies with huge vacuoles are also prone to form 
in cultures on Loffler's blood-serum. (Fig. 213.) By means of stained 
microscopical sections of the stab cultures in glucose-agar and gelatin 
it is readily shown that the peculiar later outgrowths and branchings 



650 PRINCIPLES OF SURGERY. 

observed in those cultures do not depend upon the formation of mycelium, 
but consist of budding round forms exclusively. The organism does not 
attain the same size in fluid nutrient media, potato, and other solid sub- 
stances. Eepeated budding without segmentation may give rise to chains 
and groups of various lengths and size. (Fig. 214.) 

In some cultures a distinct mycelium develops. This is most distinct 
in Pasteur's fluid and bouillon, but mycelioid growths may occur to a very 
slight extent in all media, more especially plain agar. (Fig. 215.) 

The formation of mycelium is due apparently to a gradual elongation 
of individual organisms of the smaller type, resulting in the earlier stages 
in irregularly cylindrical-shaped bodies, which later grow out into either 
curved or fairly straight, rather thick rods of varying lengths or, more 



, ^ 






* m> 



K ^f 



Fig. 214.— Chains of the Minute Form. (After Hektoen.) 

rarely, from long coiled threads. Buds may spring from any part of the 
mycelium, and they may be either sessile or pedunculated. The cylindrical 
masses, the rods, and threads vary in thickness, the average being about 
five microns. Cultures on agar-agar are frequently characterized by the 
production of a granular, yellowish-brown, at times also reddish pigment. 
Here are found medium-sized typical bodies, quite a few oblong and 
elongated, narrow, diffusely-stained forms, but no typical mycelium, and 
also a considerable number of round bodies covered and surrounded by 
yellow or yellowish-brown pigment-granules which are quite uniform in 
size. (See Fig. 215.) 

There is no pigment about the long forms. In the early stages of 
pigment formation the granules appear in the immediate vicinity of the 



[N001 l \ DION EXPER] \ir.\ CS. 



651 



outer capsule, both within as well as outside of it. As the amount of 
pigmenl increases, the endosporium disappears — a fact pointing- to a pig- 
mentary degeneration of these bodies. 

The author has been placed under obligations by Professor Hcktoen 
for the free use of his classical writings on blastomycosis and permission 
to make use of his instructive illustrations. 

INOCULATION EXPERIMENTS. 

Certain animals are susceptible to successful inoculations with frag- 
ments of blastomycetic tissue and pure cultures, and then the artificially- 
produced disease resembles the affection as it occurs in man clinically and 









Fig. 215. — Development of Pigment-granules Around and Upon some of the Larger Cells 
in Cultures on Plain Agar. Several elongated forms are present. (After Hektoen.) 

pathologically, thus furnishing the last link in the chain of evidences proving 
the etiological relationship of the fungus to the disease. 

From the specimen removed from my case Wells inserted a piece of 
tissue subcutaneously into a young rabbit. In a week an abscess de- 
veloped, reaching the size of a hickory-nut, and on the ninth day it broke 
down, forming later an ulcer, with raised margins, from which could be 
squeezed a whitish pus. A second rabbit was inoculated with this pus, and 
a swelling the size of a hazel-nut made its appearance, which subsided 
in a short time and did not reappear. The general health of the two 
animals was not impaired, and at the end of three months the one first 
inoculated was killed. Xo lesions could be found in any of the viscera. 



652 PRINCIPLES OF SURGERY. 

The pus from the abscess was carefully and repeatedly examined, stained, 
unstained, and treated with caustic potash, but the yeast-fungi could never 
be found. Cultures from the abscess-contents yielded the staphylococcus 
pyogenes aureus. It is evident that the failures in these two experiments 
were due to pus-infection caused either by the pyogenic microbes con- 
tained in the blastomycotic tissue or by contamination of the wound during 
the operation. Eabbits are very susceptible to pyogenic infection and the 
diseased tissue was eliminated by an acute suppurative inflammation be- 
fore the fungus had sufficient time to develop to reproduce the disease. 
Buschke produced in Busse's case, experimentally, follicular acneiform 
nodules through inoculation, which became necrotic at the surface in five 
days, and contained only blastomycetes. In Busse's case the disease in- 
volved the surface of the left tibia and appeared as a subperiosteal swell- 
ing, and experiments were made with its contents. Inoculations into the 
marrow of the tibia in rabbits resulted in extension of the disease over 
the entire marrow in three days. Next subperiosteal inoculation was made 
in a dog which caused rapidly-forming swellings containing a bloody dis- 
charge. Inoculation with this fluid of the peritoneal cavity in a rabbit 
provoked a plastic hemorrhagic peritonitis and enlargement of the mesen- 
teric glands. The organism was found in the inflammatory products in 
both instances. Staphylococci and other microbes were generally asso- 
ciated with blastomycetes. Subcutaneous inoculations in mice also proved 
successful. 

Buschke has shown that the duration of the appearance of the 
specific eruption varies from 6 days to 8 to 10 weeks. Hektoen inoculated 
subcutaneously with 1.5 cubic centimetres of a bouillon culture. A small 
local abscess formed. The animal died in ten days. The abscess-cavity 
contained a few cubic centimetres of a whitish-yellow viscid pus, from 
which the blastomyces grew in pure culture. The internal organs were 
sterile. 

A gray mouse died five days after receiving 1 cubic centimetre of a 
bouillon culture subcutaneously. The abscess which had formed contained 
the organism in pure culture, while the internal organs were normal. A 
medium-sized rabbit died 48 hours after subcutaneous inoculation of 2.5 
cubic centimetres of a bouillon culture. Cultures from the internal organs 
remained sterile. There was extensive coccidiosis of the liver. There were 
numerous minute foci in the lungs composed of epithelioid and giant cells, 
as well as leucocytes with considerable nuclear degeneration. In some 
of the giant cells were circular bodies resembling the organism injected, 
as well as small, round bodies that stained rather profusely with methylene- 
blue, presenting a faint peripheral transparent zone. 

A gray mouse was inoculated subcutaneously with 1 cubic centimetre 



PATHOLOGICAL anvtomy LND HISTOLOGY. 653 

of a bouillon culture, h died in five days. The small abscess contained 
the organisms, as well as staphylococcus albus; the latter organism was 

at in all the Interna] organs. 

In two rabbits injections into the anterior chamber of the eye proved 

-tul. Two intraperitoneal injection-, one in a guinea-pig and the 
other in a white rat, reproduced the disease. 

A large black rabbit received into the circulation 4 cubic centimetres 
of a bouillon suspension of a culture on beer-wort agar. It died during 
the following night. The lungs were cedematous, the thymus ecchymotic; 
the liver swollen, soft, and mottled; the spleen and kidneys appeared nor- 
mal. Smears from the various organs show numerous, clear, round bodies, 
not destroyed by IvOH: they are most numerous in the smears obtained 
from the lungs and kidneys. 

Inoculation from the various organs on glycerin-agar yielded numerous 
colonies of blastomyces, most numerous from the tubules of the kidneys. 
In his last experiment he injected 8 cubic centimetres of a bouillon culture 
into the jugular vein of a small dog, which died 26 days later. The 
autopsy and microscopical examination showed minute foci of granula- 
tion-tissue throughout the lungs and softened cellular masses, with yel- 
lowish contents, in the medullary pyramids of the kidneys. The blasto- 
mycetes were recovered in pure growth and in large numbers from the 
lungs and the kidneys. The experiments noted above, more especially those 
of Hektoen, show conclusively that dogs, mice, rats, rabbits, and guinea- 
pigs are susceptible to blastomycetic infection. There is reason to believe 
that in some of the animals in which death ensued shortly after the inocu- 
lation the fatal result, was clue to acute sepsis caused by pyogenic infection. 

PATHOLOGICAL AXATO^IY AND HISTOLOGY. 

The clinical and pathological aspects of blastomycetic dermatitis have 
much in common with tuberculosis and epithelioma, and on this account 
the differential diagnosis between these affections even at the present 
time and with the aid of modern diagnostic resources is not always easy. 
The primary efflorescences resemble acneoid infiltration at the apex of 
which necrosis takes place. In this manner crater-like ulcers form, which 
increase in width and extent to the tela subcutanea, and the ulcers later 
enlarge by confluence with sharp, zig-zag, more or less undermined and 
infiltrated margins. The margins are livid and painful, with less pain 
outside of the limits of the zone of infiltration. The discharge from the 
ulcerated surface is viscid, transparent, sometimes of a grayish color, some- 
times reddish brown, mixed with the detritus of necrosed tissue. Some- 
times the small ulcers heal in a few weeks. The new ulcers form ap- 
parently in connection with the hair-follicles, sometimes independently 



654 



PEINCIPLES OF SURGERY. 



of these, but in connection with or proximity to existing ulcers. Analo- 
gous changes in the skin take place by perforation of subcutaneous foci. 
The disease is essentially a dermatitis which develops usually in connec- 



it: 



C£s 



'■■': 





• • 




Fig. 216. — Giant Cell showing Budding Vacuolated Organism. 

tion with the cutaneous appendages, and gives rise to ulcers variable in 
size, which remain superficial and are paved with a layer of flabby, cedema- 
tous granulations. The blastomycetes are found within and between the 
cells, their favorite location being in the giant cells. The most conspicuous 




Fig. 217.— Giant Cells containing Organisms in Different Stages of Development. 



change is the marked hyperplasia of the epithelial layer of the skin. Like 
in an epithelioma, columns of epithelium are seen growing into the corium 
to a depth of about four millimetres, uniting masses of epithelial cells 



PATHOLOGICAL ANATOMY WD HISTOLOGY. 



655 



below the membrana propria to each other and to the thickened, super- 
tU'ial. epithelial Btratnm. All of the appendages of the skin are destroyed. 
The papillae arc obscured by the epithelial infiltration. In serial sections 
the papillee are in many instances seen like long, finger-like columns, often 




Fig. 218. — Giant Cell showing Organisms Apparently in Sporulation-stage. 

bending and running at right angles to the surface. (Fig. 219.) The 
primary minute abscesses are surrounded by epithelial cells and usually 
contain giant cells and the fungi. (Fig. 220.) In the central part of the 
larger epithelial columns the nuclei and the chromatic-threads are indis- 
tinct, caused by degeneration resulting from separation by a small space 




Fig. 219. — Section showing Epithelial Proliferation. Two small abscesses in an 
epithelial peg at left of field. (After Herzog.) 

from the cell-protoplasm. Leucocytic infiltration is marked and miliary 
abscesses are numerous in the epithelial masses. When the embryonal 
cells are less numerous the subcutaneous connective tissue is made up 
of cedematous cells, which bear a strong resemblance to myxomatous tissue 



656 



PRINCIPLES OF SURGERY. 



and containing in their meshes eosin-staining granules. In contradis- 
tinction to the tubercle nodule the masses of granulation-tissue in the 
blastomycetic product are very vascular. The giant cells constantly found 
in the corium and so numerous in the deeper portion of the inflammatory 
product are identical in form, size, and peripheral radiate arrangement 
of the nuclei with the typical giant cell of a Langhans tubercle. Vacuola- 
tion — to a greater or less extent — is an almost constant feature. The 
parasites are most constantly found in the miliary abscesses and in the 
giant cells. 



^£^^0^^^ 




ms^S^^^^&^^&. 


t r: 


Ic,- i -v-- :^ '0 y^yW$?r. 





Fig. 220.— Miliary Abscess of Blastomycetic Dermatitis containing Two Giant Cells in the 
Centre and Two Organisms in the Lower Part of the Minute Cavity. 



•DIAGNOSIS. 

For the general practitioner the diagnosis of blastomycetic dermatitis 
will always remain difficult and often impossible. If he wants to be sure 
he must call into consultation a competent microscopist. All we can ex- 
pect of him is to possess enough knowledge of the clinical features and 
pathological aspects to suspect the disease when he sees it, and rely on a 
positive diagnosis by furnishing an expert pieces of tissue from the periph- 
ery of the inflammatory product for microscopical examination. It is in 
the newest parts of the inflammatory product that the organisms and giant 
cells are most numerous. The practitioner may suspect blastomycosis in 
cases in which an isolated territory of the skin becomes the seat of acne- 
like pustules followed by minute excavated ulcers which by confluence 
give rise to progressive extensive destruction of the skin. A tendency to 
healing of the small ulcers is often manifested, but new eruptions are sure 
to arise in the neighborhood of the minute, imperfectly-developed scars. 
It is as yet a disputed question whether blastomycetic infection can take 
place through the intact skin; there is, however, very little doubt concern- 
ing primary infection through the appendages of the skin. In such in- 



DIAGNOSIS. G57- 

stances the presence of the organisms excites a folliculitis which results 
in obstruction of the outlet of the gland and penetration of the in- 
flamed gland-wall by the blastomycetes. The occurrence of multiple 
acneoid pustules in close proximity to each other, followed by necrosis 
and punctiform excavated ulcers, should always call attention to blasto- 
mycosis. If these minute ulcers coalesce and progressive ulceration 
leads to extensive surface destruction, the probability of the ulcer being 
blastomycetic is greatly increased. The two skin affections which are 
most likely to be mistaken for blastomycosis are tuberculosis and 
epithelioma. In tuberculosis of the skin, represented by lupus vulgaris 
of the eld authors, the disease does not so often start from multiple 
primary points of infection and the ulceration is more likely to penetrate 
the tissues deeper and to invade, in its course, tissues irrespective of their 
anatomical structure, while in blastomycosis the destructive process begins 
in and is largely limited to the skin, the ulcer remaining superficial. 
Epithelioma exhibits its anatomical points of predilection to a greater 
extent than blastomycosis. The disease begins at one particular point and 
the destructive process extends from one common centre and in its course 
invades tissues regardless of their anatomical structure and physiological 
properties. The induration of the base and margins of the nicer are more 
marked in epithelioma than in blastomycetic dermatitis. If anything, the 
pain and tenderness in blastomycosis are more important clinical wit- 
nesses of blastomycosis than epithelioma. The nature of the discharge is also 
an important clinical criterion between a blastomycetic and an epitheli- 
omatous ulcer. In the former the secretion is viscid, in the latter serous. 
In an epithelial ulcer under pressure a solid substance can be squeezed out, 
representing the degenerated epithelial cells of the superficial ulcerating 
carcinoma-nests. Glandular involvement, as a rule, is absent in blasto- 
mycosis, while in epithelioma it appears infallibly, sooner or later, in the 
clinical course of the disease. Finally, in epithelioma very often the clini- 
cal history points to an hereditary aptitude for the disease wdiile no such 
predisposition can be assigned to blastomycosis. Tertiary syphilitic ulcer- 
ations following softening and breaking down of gummata bear often a 
close resemblance to the disease. But in syphilitic ulcerative affections of 
the skin the clinical history will often come to our aid in making a differ- 
ential diagnosis, strengthened by the discovery of syphilitic lesions in 
other parts of the body and the existence of universal hyperplasia of the 
lymphatic glands. Every surgeon is well aware of the fact that, while the 
clinical course of blastomycetic dermatitis and the gross pathological 
appearances of tissue-changes are well calculated to arouse suspicions 
concerning the nature of the ulcerative process, the final diagnosis must 
rest on microscopical examinations of the diseased tissues. The discovery 



*658 PRINCIPLES OF SURGERY. 

of the parasites in the inflammatory product completes the diagnosis as far 
as the existence of blastomycosis is concerned, but does not exclude the 
existence of complications, such as tuberculosis and syphilis, as has been 
shown by the cases reported by Hyde, Hektoen, and Bevan, and Anthony 
and Herzog. Should the examination of tissue removed for diagnostic 
purposes leave any doubt as to the nature of the ulcer, the last and 
most reliable diagnostic resource must be resorted to, namely: inoculation 
experiments. These will yield positive results in blastomycosis and tuber- 
culosis and negative results in syphilis and epithelioma. In the former 
instance a final differential diagnosis will be made by a bacteriological exam- 
ination of the tissues of the diseases artificially produced. 

PROGNOSIS. 

Blastomycetic dermatitis manifests no tendencies to permanent heal- 
ing of the ulcer. Attempts in this direction are constantly followed by 
local aggravated relapses. The intrinsic tendency of the disease is to 
progressive extension. During the early stages of the disease it is amen- 
able to successful treatment by any methods which destroy its essential 
parasitic cause. After the disease has become extensive and in neglected 
cases the danger to life arises from metastatic processes involving inter- 
nal organs, as has been shown by Busse's case and the interesting ex- 
perimental work of Professor Hektoen. 

TREATMENT. 

. Blastomycetic dermatitis is amenable to early efficient surgical treat- 
ment. In the absence of metastatic processes in important internal organs 
the disease yields to any method of treatment which insures complete 
removal or destruction of the infected tissues. The surest way to accom- 
plish this is by a clean and complete excision. As the disease is always 
superficial, this can be accomplished with safety and precision. If the dis- 
ease is limited, the resulting wound can be closed by suturing; if more 
extensive, it is paved with Thiersch's skin-grafts, and in large defects it 
becomes necessary to resort at once to a plastic operation, which yielded 
such a satisfactory result in the author's case. In cases in which the diag- 
nosis remains doubtful and in instances in which a radical operation is 
contraindicated. either on account of the extent of the disease or the 
existence of metastatic foci, the administration of potassic iodide deserves 
a fair and extended trial. The dose administered internally should be 
gradually increased from 1 to 4 or 6 grammes four times a day. The 
author strongly recommends, in connection with gradually-increasing 
doses administered internally, the local endermic use of a 15-per-cent. 
solution of the same drug by cataphoresis. 



CHAPTER XXVI. 



Anthrax. 



Synonyms. — Contagious carbuncle; charbon; Milzbrand; malignant 
pustule; wool-sorters* disease. The mycology of anthrax is better "under- 
stood than that of any other microbic disease. The bacillus of anthrax 
is the largest of the known pathogenic microbes, and ever since it was 

ivered it lias been a favorite subject of investigation in every labora- 
tory and by every bacteriologist. 

HISTORY. 

A.s a disease among animals, anthrax has been known since the 
earliest records of history. The contagiousness of this disease has been 
recognized since the beginnning of the eighteenth century. During the 
first part of the present century it was described as a blood disease. 
Heusinger, in his classical work, "Die Milzbrand Krankheiten der Thiere 
und des VTenschen" (Erlangen, 1850), declared anthrax to be a malarial 
neurosis. In the year 1855 Pollender published his discoveries, which 
inaugurated a new era in the study of anthrax. As early as 1819 he dis- 
covered, in the blood of cattle suffering from anthrax, a mass of innumer- 
able, fine, rod-like bodies which appeared to be of a vegetable nature and 
resembled vibriones. Brauell found the same rods in the blood of men, 
horses, and sheep which had died of anthrax. He also detected the same 
bodies during life in the blood of the diseased animals. Delafond regarded 
this parasite as a variety of leptothrix. In 1863 appeared the work of 
Davaine, wherein he pronounced these rods to be bacteria, and later he 
called them bacteridia. He believed them to be the essential cause of 
anthrax, as the disease could not be found in the blood that did not con- 
tain them. Through the labors of Pasteur, Koch, Naegeli, Bollinger, and 
others, the bacterium found so constantly in the blood and tissues of 
anthracic animals finally found a permanent place as the bacillus anthracis 
among the schizomycetes. 

The first reliable and positive accounts of the disease in man we owe 
to Fournier. Montfils, Thomassin, and Chabert, who published their de- 
scription of the disease between the years 1769 and 1780. Fournier first 
distinguished the spontaneous and the communicated carbuncle of man. 
The primary existence of anthrax in man was asserted by Bayle in 1800 
and by Davy la Chevrie in 1807. 

(659) 



660 



PRINCIPLES OF SURGERY. 



DESCRIPTION OF THE BACILLUS OF ANTHRAX. 

Non-motile rods, 5 to 10 micromillimetres long and 1 to 1.25 micro- 
millimetres broad, and threads made up of rods and cocci. 

The rods, as a rule, are straight; only when they grow to a consider- 
able length and meet with resistance they become slightly curved. The 
rods and threads are round, and, with their threads truncated at right 
angles, appear as though they had been cut of! obliquely. The interior, 
as long as fission does not proceed, is perfectly homogeneous, and ab- 
sorbs aniline dyes very readily and uniformly. The development of spores 
in long, undivided threads, as we find them in fluid culture-media, takes 
place at regular intervals, where we find them as bright, oval spots that 
become more and more apparent, marking the direction of the rods. Upon 
solid culture-media the development of spores is preceded by transverse 




<^ 



,g o ° 
6b «» 



0$> 



@, 



© 



Fig. 221. — Anthrax Bacilli: Spore-formation and Spore-germination. A, from the 
spleen of a mouse after twenty-four hours' cultivation in aqueous humor. Spores ar- 
ranged in rods like a string of pearls. X 650. B, germination of spores. X 650. C, the 
same, greatly magnified. X 1650. (Koch.) 



segmentation of the rods. The cell-membrane of each section finally be- 
comes the membrane of the spore, each pole of the spore presenting a 
small mass of protoplasm that can be stained. 

(a) Staining. — Cover-glass preparations of fluid specimens can be 
stained with a watery solution of any of the aniline dyes. They can be 
rapidly stained with a drop of fuchsin or gentian-violet, but more satis- 
factorily by floating the cover-glass for twenty-four hours. The prepara- 
tions are dried and mounted in Canada balsam. The spores are not stained 
by the ordinary methods. Tissue-sections containing bacilli are best 
stained by Gram's method, and after-stained with eosin or picro-carminate 
of ammonium. By double staining the rods are seen to consist of a hya- 
line sheath with protoplasmic contents. 

(b) Cultivation. — The bacillus of anthrax grows luxuriantly in dif- 



DESCRIPTION 0] 



BACILLI'S OF AN nil! \\. 



«61 



ferenl fluid and solid nutrient media. Bouillon and aqueous humor of the 
eye furnish an excellent soil, but for inoculation purposes the cultures are 
now generally grown upon solid nutrient media. 

Gelatin. — If a nutrient medium containing from 5 to 8 per cent, of 
gelatin is inoculated, a whitish line develops in the track of the needle- 
punqture, and from it fine filaments spread out on the sides. 

In a more solid nutrient gelatin the growth appears only as a thick, 
white thread. The culture liquefies the gelatin, and the growth subsides 
as a white, flocculent mass. 




Fig. 222.— Stab-culture of Anthrax Bacilli in Gelatin, Grown at Room-temperature 
(16° to 18° C.). Four days old. Natural size. (Baumgarten.) 



Plate Cultures. — Cultures upon a sloping surface of solid nutrient 
agar-agar or gelatin form a viscous, snow-white plaque. 

Without access of air the culture does not grow, the bacilli being 
aerobic. 

Potato. — Inoculation of sterilized potato yields a very characteristic 
growth. The deep chamber containing the potato is placed in the incu- 
bator, and in about thirty-six or forty-eight hours a creamy, very faintly 
yellowish layer forms over the inoculated surface, with, usually, a peculiar 
translucent edge. On removing the cover of the damp chamber, a strong, 
penetrating odor of sour milk is emitted. 



662 PRINCIPLES OF SURGERY. 

MULTIPLICATION OE ANTHRAX BACILLI IN THE LIVING BODY 
AND THE SOIL. 

In the body of living animals the bacilli multiply exclusively by seg- 
mentation, and never produce spores. Spores are produced only in dead 
nutrient media, and under certain conditions only, among which a proper 
temperature is the most important factor. The limits of the temperature 
vary between 12 to 18° C. and 13° C; at a temperature of less than 
12° C. growth of the rods and spore-production no longer take place. 
Pasteur's assertion that bacilli and spores in the cadavers of buried ani- 
mals are active when brought to the surface by earth-worms is improbable. 
The disease, according to Koch, is spread among animals by germinating 
spores which attach themselves to plants and grass in swamps and along 
river-banks, and which, when taken in with the food, become the cause of 
intestinal anthrax. 

Schrakamp and Friedrich are of the opinion that bacilli can multiply 
in the superficial layer of the soil, while Kitt maintains that fructification 
of the bacilli takes place in the manure deposited in pastures. 

INOCULATION EXPERIMENTS. 

In order to cause death of animals by inoculation with the bacillus of 
anthrax, a pure culture of anthracic blood must be injected into the sub- 
cutaneous tissue or into the circulation, or the virus may be transmitted 
by inhalation or by feeding. Goats, hedgehogs, mice, sparrows, cows, 
horses, guinea-pigs, and sheep can be readily infected. Eats are less sus- 
ceptible. Pigs, dogs, cats, white rats, and Algerian sheep are immune. 
Frogs and fish have been rendered susceptible to anthracic infection by 
raising the temperature of the water in which they lived. Koch produced 
the disease artificially in rabbits and mice by injecting a drop of anthracic 
blood, with the result of producing death usually within twenty-four 
hours. After death sections taken from different organs, stained in 
methyl-violet with carbonate of potash, were examined under the micro- 
scope, and the bacillus was found in great abundance in all of them. 
When magnified fifty diameters such preparations present, at the first 
glance, an appearance as if a blue coloring material had been injected 
into the vessels. Each intestinal villus is permeated by an exceedingly- 
delicate blue net- work; in the mucous membrane of the stomach all the 
capillaries surrounding the gastric glands are stained blue; in the ciliary 
process each projection is injected, and a spiral vessel stained of a dark- 
blue color leads from thence to the iris and breaks up into a fine, blue 
net-work, with loops directed toward the edge of the iris. The liver and 
lungs and the glandular structures, such as the pancreas and salivary 



i\o» i i. a thin i:\I'i:i;imi:\ CS. 663 

glands, are completely permeated by the Bame blue, vascular net-work. 
Indeed, there is no organ which is not more or less injected with the 
blue mass. It is, however, very striking thai this injection is only 
:it in the capillary vessels. All the larger vessels, even the arteries 
and veins of an intestinal villus, are either not at all stained or have but a 
light-blue streak in their interior, and that only here and there. When 
magnified 850 times one can Bee that the blue capillary net-work is com- 
posed of numerous delicate rods, and when a power of 700 diameters is 
used it is found that the apparent injection is nothing more or less than 
the bacillus anthracis, stained dark-blue, and present in incredible num- 
bers in the whole capillary system. 





Fig. 223.— Anthrax Colony upon Gelatin. A, after twenty-four hours; B, after 
forty-eight hours. X 80. (Fliirjac. I 

In the other vessels, especially in the larger ones, often only a single 
bacillus may be met with at long intervals, or they may be quite absent. 

The distribution of the bacillus in the capillaries is not, however, 
quite uniform. There are fewer in the brain, in the skin, in the capillaries 
of the muscle, and in the tongue than elsewhere; on the other hand, in 
the liver, lungs, kidneys, spleen, intestines, and stomach they are always 
present in enormous numbers. In the capillaries themselves the bacilli 
accumulate in largest numbers at the point most distant from the nearest 
afferent artery and the efferent vein; that is. at points where the blood- 
current is slowest. Where the bacilli are present in greatest abundance it 
not unfrequently happens that the capillaries become torn, and blood, 
with the contained bacilli, is extravasated. This occurs most frequently 



66± 



PEIXCIPLES OF SUBGEEY. 



in the glomeruli. Many of these burst, and the bacilli pass into the 
uriniferous tubules. In mice the spleen is more especially the seat of the 
bacilli; then come the lungs and, last of all, the kidneys. Frisch inocu- 
lated the cornea in animals and produced a keratitis, caused by the bacilli, 
which multiplied with great rapidity, local dissemination taking place 
through the corneal spaces. 



fZ' 




1 1 eA 



Fig. 224. — Intestinal Villus of Anthracic Rabbit. The bacilli in capillary vessels 
alone stained. X 250. {Koeh.)' L 



IXFECTION IN MAX. 

An intact skin furnishes ample protection against infection with 
bacilli or spores, but the slightest abrasion may become the necessary in- 
fection-atrium for either method of infection. Machnoff rubbed agar- 
agar cultures of anthrax bacilli mixed with a little lanolin into the shorn 
skin of rabbits and in every instance the animal died about the third day 
of acute general anthrax. The skin showed no microscopical lesions, but 
bacilli were found in the hair-follicles. The animals in which the same 
substance was simply applied to the skin did not contract the disease. 
During the act of rubbing the microbes are forced into the hair-follicles, 
from which they enter the tissues and the general circulation. Infection 
may occur through a healthy mucous membrane, either with bacilli or 
spores. As the anthrax bacillus is a non-motile parasite, penetration of 
the epithelial lining can only occur by local growth of the bacillus. 
Spores are such minute structures that they can reach the circulation 



1 Copied from "Traumatic Infective Diseases, 
Society, London. 



by permission of the New Sydenham 



[NFECTION IN MAN. 

through a healthy mucoua membrane in the same manner and by means 
of the same agencies as we have found necessary for the transportation of 

other minute foreign parasites from the mucous surface into the circu- 
lation. Ollivier reports the ease of a baby. 5 months old, supposed to 
have bronchitis. The chesl yielded all the physical signs of 

bronchitis, but in addition there was some ueneral oedema and an erythem- 
atous patch upon the upper left chest. After death, on the ninth day, 
the "pustules" were found in the bronchi. In this case infection was 
caused by the entrance of bacilli or spores through the bronchial mucous 
membrane. Petrov reports a case of pulmonary anthrax which resulted 
in death on the fifth day. At the autopsy numerous anthrax bacilli were 
found in the lymphatics of the lungs. Bonisson reports a case in which 









Fig. 225.— Bacillus Anthracis. From a section of kidney of a mouse. (Gram"s method 
and eosin. Zeiss V12 o.i., ocular 2.) (After Vrookshank.) 

infection evidently occurred through the mucous membrane of the in- 
testinal canal. During life the diagnosis made was intestinal obstruction. 
The autopsy showed great congestion of the intestines; the mesenteric 
glands were greatly enlarged. One loop of the intestine was greatly swollen, 
and a thrombus twenty centimetres long was found in the immediate 
neighborhood. In this case bacilli were found in the blond. Zorkendorfer 
records another case of primary intestinal anthrax. The bacilli were 
found in the blood and organs, but they were most numerous in the in- 
testinal lesions. A third case came under the personal observation of 
Krumbholz. The disease was marked by choleraic symptoms. Bacilli 
were found in the peritoneal exudate and the blood, and microscopical 
examination showed that they had entered from tin- Intestinal wall into 

42a 



666 PRINCIPLES OF SURGERY. 

the peritoneal cavity through the lymphatics. In man infection fre- 
quently takes place through a small wound or abrasion in persons handling 
the infected products of anthracic animals, such as wool, hair, and hides. 
In other instances, insects, such as mosquitoes and flies, that have fed on 
the blood of living anthracic animals or the dead tissues of animals that 
died of the disease, may become disease-carriers. The sting of such an 
infected insect may communicate the disease with the same degree of 
certainty as an intentional inoculation with a drop of anthracic blood or a 
minute quantity of a pure culture. 

INTENSIFICATION OF YIBTTS. 

While it is known that some chemical substances exert an attenuating 
influence on the virulence of the anthrax bacillus, it has also been found 
that an attenuated virus will again become more virulent by adding cer- 
tain Substances. It must, therefore, be taken for granted that the chem- 
ical composition in which the bacillus is suspended influences, in one way 
or the other, its virulence. It has been found, for instance, that the addi- 
tion of a minute quantity of lactic acid to a fluid containing the bacillus 
in an attenuated form greatly intensifies its virulence within a very short 
time. Thus, Arloing, Cornevin, and Thomas found that the pathogenic 
power of a fluid containing these bacilli, to which 1 / 500 part of lactic acid 
had been added, and the mixture allowed to stand for twenty-four hours, 
was increased twofold; if, then, a little water, containing a very easily 
fermentescible sugar, is added to the mixture, and another twenty-four 
hours allowed to elapse, the virulence attains its maximum, and frogs 
inoculated with this virus die in from twelve to fifteen hours; whereas, 
when inoculated with ordinary virus, they live from forty to fifty hours. 
Kitt has repeated and confirmed these experiments. 

ATTENUATION OF VIRUS AND PROPHYLACTIC INOCULATIONS. 

By cultivating the bacillus of anthrax in neutralized bouillon at 42° 
to 43° C, (107.6° to 109.4° F.) for about twenty days, the infecting power 
is weakened, and animals inoculated with it are protected against the 
disease. A still greater degree of immunity is obtained by inoculating a 
second time with material that has been less weakened. Animals thus 
treated are then protected against the most virulent form of anthrax, but 
only for a time. A temperature of 55° C. (131° F.), or treatment with 
1- to 5-per-cent. solution of carbolic acid, deprives the bacilli of their viru- 
lence. The virulence of the bacillus is also altered by passing it through 
different species of animals. Woolbridge secured immunity against an- 
thrax in animals by cultivating the bacillus in an alkaline solution at a 
temperature of 37° C. (98.6° F.) for two days. At this time the fluid was 



aiii:m \no\ or 7IBUS LND PBOPHYLACTIC [NOOULATIONS. 667 

filtered and a small quantity of the filtrate Injected into the subcutaneous 
tissue of rabbits; these rabbits remained well, and subsequently resisted 
injection of most virulent anthracic blood. 

Ilankin. under the guidance of Koch, at the Hygienic Institute of 
Berlin, isolated an albuminose from anthrax cultures, which, when in- 
jected into rabbits and mice in small quantities, rendered these animals 
immune against the most virulent cultures. The albuminose was pre- 
pared from the cultures by precipitation with absolute alcohol; the pre- 
cipitate was well washed in this liquid to free it from toxins, — since it is 
known that all such substances are soluble in alcohol. After the addi- 
tion of alcohol it was filtered oft' and dried, then redissolved and filtered 
through Chamberland's filter. Four rabbits were inoculated with virulent 
anthrax spores, and 3 of them received an injection of albuminose into 
the ear-vein at the same time; the latter recovered, while the remaining 
animal not thus protected died, in about forty-eight hours, of anthrax. 
In another experiment 10 mice were each injected with the millionth part 
of their body-weight of anthrax albuminose and with active vaccine at 
the same time. Of these, 3 died after 108 to 116 hours; the others re- 
covered. Three others had only the two-millionth part of their body- 
weight of anthrax albuminose and active culture. Two of them survived. 
Four control mice were inoculated, and all died of anthrax. He has come 
to the conclusion that when a large dose of albuminose is injected into 
an animal the entrance of anthrax bacilli into the system is aided, and 
when a small dose is administered immunity is acquired against its poison- 
ous properties, protecting the animal against subsequent inoculations with 
active cultures. It has been recently shown, by the experiments of Ogata 
and Jasuhara, that when the bacillus of anthrax is cultivated in the blood 
of an immune animal, its pathogenic power is modified so that it no longer 
kills susceptible animals, and may be used as a protective vaccine-material. 
Prophylactic inoculations of sheep with mitigated virus have been carried on 
upon an extensive scale in France by the late Pasteur and his pupils, and 
recent statistics bearing upon their value in protecting animals against 
anthrax have shown them effective in preventing the spread of the disease 
in infected districts. 

More recent bacteriological investigations have shown that an antag- 
onistic action exists between the bacillus of anthrax and other pathogenic 
microbes, notably the diplococcus pneumonia?, the streptococcus of erysip- 
elas, the staphylococcus pyogenes aureus, and the bacillus prodigiosus. 
Experiments have shown that the growth of anthrax may be retarded or 
destroyed entirely, according to the quantity of the antagonist injected. 
This discovery will result in additional resources in effecting immunity 
and open a new field in the treatment of this disease. 



PRINCIPLES Of SURGERY. 



CLIXICAL VARIETIES OE ANTHRAX. 

Primary bronchial and pulmonary anthrax, caused by the inhalation 
of dust containing bacilli or spores, and primary anthrax of the intes- 
tines, caused by eating anthracic meat or by drinking water infected with 
spores, are diseases that are occasionally met with in man; but, as these 
affections belong to the physician and not to the surgeon, the student 
should consult any of the modern text-books on the practice of medicine 
to become familiar with their symptomatology. 

Buchner has studied experimentally the entrance of the anthrax 
bacillus through the intact mucous membrane of the bronchial tubes. 
The bacillus and spores were administered by inhalations, in the shape of 
dry powder, and suspended in steam. On examining the bronchial mucous 
membrane at different stages, under the microscope, it was seen that the 
spores were transformed in a very short time into bacilli, and that the 
latter, by their growth, pushed themselves between the cells and into the 
capillary vessels. It was observed that, the greater the pulmonary irrita- 
tion, the more the passage of the microbes was retarded. The entrance of 
the bacilli from the surface of the mucous membrane into the capillary 
vessels was seen to depend on an active process. 

Secondary anthracic bronchitis, pneumonia, and enteritis are met with 
in almost all cases of localized anthrax followed by secondary general in- 
fection. Primary intestinal anthrax in man was studied by TTahl, Keck- 
linghausen, Buhl, Wagner, Bollinger. Leube. and Frankel. and all of these 
authors succeeded in demonstrating the presence of the essential microbic 
cause in the inflamed mucous membrane. When the microbe enters the 
body through the mucous membrane of the gastro-intestinal canal with 
the food or drink, it gives rise to a primary anthrax of the intestinal canal, 
that again may become general by metastatic dissemination through the 
systemic circulation. Localization upon the mucous surface first takes 
place upon the most prominent part of the valvuhe conniventes on the 
mesenteric side of the bowel, and from here the infection spreads over 
the entire surface. Yierhoff has collected 41 cases of anthrax intestinalis, 
the total number found reported up to 1SS5. The author himself observed 
2 cases of secondary intestinal anthrax in the hospital at Eiga. Oases 
of secondary intestinal anthrax — that is. localization of the bacillus of 
anthrax in the mucous membrane of the intestinal canal after external 
ion — were known to the older authors, while observations of pri- 
mary localization in the digestive tract date only from the middle of 
the last century. As soon as general infection has taken place, the dif- 
fusion throughout the capillary system is the same as has been described 
under the head of "'Inoculation Experiments.*'* The forms of anthrax 



CLINICAL 7ABIETIES OF w I BR AX. 669 

that concern the Burgeon most are those which result from infection of 
the external Burface by the introduction of the bacilli or spores through 
a -mall wound, abrasion, or the sting of an infected insect. The favorite 
Location for the development and growth of the anthrax bacillus in man 
and beae - in the connective tissue; it is, therefore, immaterial in what 
manner the microbe reaches this tissue, as localization here marks the 
beginning of the disease. The clinical forms vary according to the localiza- 
tion of the disease, its extent, and the intensity of the infection. Most 
all authors follow Bollinger's classification, according to which all cases 
are brought under one of the following varieties: 1. Anthrax acutissimus, 
or apoplectiformis. 2. Acutis. 3. Subacutis. 

The primary location of the disease is in accordance with the manner 
in which infection has taken place. TV. Koch states that in animals and 
man the bacillus can enter the organism through one of the following 
routes: (a) through the skin; (b) gastro-intestinal canal; (c) respiratory 
passages. 

Anthrax of the External Surface. — Infection of the subepidermal con- 
nective tissue can only occur through a defect in the epidermis; hence, 
every anthrax of the external surface corresponds in its location with an 
infection-atrium, through which the essential microbic cause has entered 
the connective tissue. The bacillus of anthrax, when brought in contact 
with living tissue susceptible to its pathogenic action, causes an acute 
inflammation characterized by grave alterations of the capillary wall and 
rapid exudation. The microbe first multiplies at the primary point of 
invasion, and, if it does not meet with sufficient tissue-resistance, it enters 
the blood-vessels and causes general infection, which always proves fatal. 
Infection occurs most frequently in exposed parts of the body; thus, of 63 
cases of anthrax in man, collected by Slessarewskji, the disease showed 
itself 6 times on the face, 21 times on the neck, and 36 times in other 
places. Trousseau relates that in Paris 20 persons were attacked with 
anthrax in ten years, and in all of them the source of infection could be 
traced to horse-hair imported from South America. The pathologico-ana- 
tomical conditions vary according to the primary seat of invasion, the 
structure of the organ, and seat of the disease. The first tissue-changes 
are observed at the point of inoculation. From a prognostic and patho- 
logical point of view external anthrax can be divided into two distinct 
varieties: 1. Anthrax pustule. 2. Anthrax oedema. 

1. Anthrax Pustule. — This is the so-called malignant pustule. It is 
usually met with in parts not covered by clothing, as the fingers, hands, 
and face. The only case of anthrax pustule that has come under the 
observation of the writer occurred in the palm of the hand in the person 
of a robust butcher. The base of the pustule attained the size of a silver 



670 PRINCIPLES OF SURGERY. 

dollar and was very hard. The surface of the pustule sloughed, leaving 
a granulating surface, which healed slowly under antiseptic treatment. 
This form of the disease is determined by the anatomical structure of 
the part affected, which must be dense and vascular. The pustule begins 
as a small, red point that resembles the bite of a flea, in the middle of 
which a small vesicle appears, which, at first, contains a transparent 
serum, and, later, becomes sanguineous. The patient complains of an 
itching, burning sensation. The skin around the centre of the pustule is 
at first slightly raised by the inflammatory infiltration underneath it. 
"Within twenty-four or forty-eight hours the size of the infiltrated area is 
as large as a nickel, and the inflamed part presents all the evidences of a 
very acute circumscribed inflammation. The swelling is now painful, 
tender on pressure, and exceedingly firm to the touch. The centre, pre- 
viously occupied by a vesicle, is of a brownish-red or blackish-gray color, 
and presents indications of approaching gangrene. The epidermis ex- 
foliates, exposing a necrosed area the size of a pea to a silver half-dollar. 
The dead tissue remains firmly connected with the surrounding indurated 
parts, until it becomes gradually detached in the course of the suppura- 
tive inflammation, which ensues sooner or later. After separation of the 
slough, spontaneous healing may take place, always leaving a depressed 
scar. In this form of anthrax general infection seldom occurs, as the 
infection remains local, the early and abundant inflammatory exudation 
forming an impermeable wall around the infected zone, beyond which the 
bacilli cannot escape. General infection, however, in such cases occa- 
sionally takes place where a vein becomes implicated in the process, and 
general infection is not prevented by the formation of a plastic thrombus 
on the proximal side of the intravenous culture. The acuteness of the 
inflammation, and probably, also, the direct necrotic effect of the toxins 
of the bacilli, invariably result in necrosis of the central portion of the 
pustule, which is the most characteristic pathological and clinical feature 
of this form of anthrax. 

2. Anthrax (Edema.- — This form of anthrax follows infection, if the 
tissues around the infection-atrium are freely supplied with loose con- 
nective tissue and the blood-supply to the part is scanty: conditions which 
are present about the eyelids, neck, and forearm. Anthrax in these 
localities appears as a flat infiltration without well-defined borders, and 
with little or no discoloration of the skin. In a case of this kind that 
came under my care the primary infection occurred in the temporal region 
above the external ear. The patient was a cattle-dealer about -iO years 
of age. The oedema spread very rapidly, and with the local extension the 
septic symptoms increased proportionately. Death at the end of the 
second week was preceded by symptoms indicative of internal sepsis. 



PATH0L0G1 and MORBID anatomy. 67] 

From the infiltrated tissue- a rapidly-spreading oedema extends in all 
directions. This form of anthrax is attended by greater dangei of general 
infection than anthrax pustule, as the bacilli are less effectually walled 
in by the inflammatory product. Vesication, exfoliation of cuticle, and 
gangrene may also take place, and in milder cases a spontaneous cure is 
le. A.s Long as the infection remains local general symptoms are 
absent, but as soon as general infection has occurred they point to progressive 
caemia. 

PATHOLOGY AND MORBID kNATOMY. 

If the tissues of a primary anthrax of the external surface are ex- 
amined under the microscope, all the appearances of an acute non- 
suppurative inflammation are shown. The specific effect of the bacillus 
on the tissues results in serious alteration of the capillary vessels, which 
gives rise to an abundant inflammatory exudation. In malignant pustule, 
or anthrax pustule, the paravascular and connective-tissue spaces become 
completely blocked with leucocytes in a remarkably short time, and ne- 
crosis of the central portion of the inflammatory product is a constant 
result of the acute ischaemia and the speedy coagulation-necrosis thus 
produced. Anthracic inflammation never terminates in suppuration 
unless secondary infection with pus-microbes takes place. The local 
oedema in the cedematous variety, at the point of infection, is caused by 
vascular disturbances due to the presence of the bacilli within the blood- 
vessels and the interstitial inflammatory exudation caused by their pres- 
ence. In fatal cases the necropsy reveals the same changes in different 
organs as Koch has described in his experiments on rabbits. The capil- 
lary vessels in every part of the body will be found completely or partially 
blocked with bacilli, but the number of microbes is always greatest in the 
most vascular organs, as the spleen, liver, and kidneys. 

The bacilli, as in mice-septicaemia, will be found in the capillary ves- 
sels arranged in the direction of the blood-current, and most numerous 
where the flow of blood is most impeded, as at points of intersection. 
General infection always takes place through blood-vessels. The inter- 
nal organs are found enlarged and exceedingly vascular from engorge- 
ment caused by the capillary obstruction. Minute extravasations are 
found in different organs where the bacilli are most numerous, resulting 
in complete destruction of the capillary wall and rhexis. The secondary 
intestinal affection most frequently assumes the form of inflammatory 
haemorrhagic infiltration, more seldom that of haemorrhagic catarrh; ulcer- 
ations the size of a split pea to 2 inches in diameter are frequently pres- 
ent, the remaining portion of the mucous membrane showing well-marked 
evidences of acute inflammation, great vascularil v. and infiltration. 



672 



PRINCIPLES OF SURGERY 



Mesenteric glands are swollen and contain numerous bacilli. The bron- 
chial and intestinal mucous membranes exhibit all the appearances of recent 
inflammatory changes, great vascularity, slight thickening, and here and 
there minute extravasations. In some cases the meninges of the brain 
show well-marked lesions that account for the cerebral symptoms during 
life. Pathologists have often failed in locating the immediate cause of 
death in fatal cases of anthrax, and various theories have been advanced 
at different times to determine this point. 






tfemM^ 



tSfiiifsi}© 



Ifjfiiy till 

Fig. 226.— Anthrax: Section from Liver. X 700. (Fliigge.) 

In the most virulent form, the anthrax acutissimus, Bollinger be- 
lieves that the rapid growth of the bacillus in the blood brings about a 
sudden diminution of oxygen and a surplus of carbonic acid, and that 
death takes place by a slow process of asphyxia. Against this theory it 
can be maintained that, in the blood of animals that have died of the 
acutest form of the disease, comparatively few bacilli are found; and, 
further, that in the experiments made by Nencki, on the blood of rabbits 
that had died of this form of anthrax, it was found as capable of oxy- 
genation as the blood of healthy animals. The theory that death results 
from purely mechanical causes due to the presence of bacilli in great 



PATHOLOGY AND MORBID ANATOMY. 673 

abundance in the blood-vessels is likewise not tenable, because no such 
fatal degree of obstruction in the capillary circulation has been found at 
the post-mortem examinations. As a third hypothesis, Bollinger advanced 
that the bacillus may generate a chemical poison that may cause death by 
intoxication. In reference to the last-mentioned cause, Hoffa calls atten- 
tion to the following three possibilities: — ■ 

1. The bacilli of anthrax are in themselves poisonous, and the in- 
crease in their number increases the quantity of the poison in the same 
ratio. Against this supposition the results of the experiments made by 
Hoffa himself furnish the most conclusive proof. Of a pure culture of 
anthrax bacilli he injected a large quantity directly into the jugular veins 
of rabbits. The animals thus infected showed no symptoms of acute in- 
toxication, but died in the same manner as animals infected in the usual 
way. 

2. The bacilli of anthrax produce a poison capable of causing fer- 
mentation in the blood; this poison is soluble in the blood. The fact 
that filtered blood of animals that had died of anthrax did not produce 
toxic symptoms when injected into healthy animals speaks against this 
argument. 

3. The bacillus of anthrax separates toxic substances from complex 
combinations in the organism. This last explanation appears, from 
analogy of the views that are now entertained of bacteria and toxins, to 
be the most plausible, and he made an effort to produce such substances 
outside of the animal body, upon artificial culture-media. For this pur- 
pose he cultivated the bacillus with the greatest precautions upon sterilized 
meat kept for several weeks in an incubator at 37° C. (98.6° F.). The 
chemical product thus obtained he attenuated according to the methods 
advised by Stass-Otto, Brieger, and after the more recent method of 
Fischer. 

By the methods of Stass-Otto and Fischer he succeeded in producing 
a substance that possessed an alkaline reaction, and produced toxic effects 
in animals. A strictly-pure article and an accurate chemical description 
of it could not be obtained, on account of the smallness of the quantity 
produced. The substance produced by Stass-Otto's method was used in 
experimenting on frogs, mice, guinea-pigs, and rabbits; both of them pro- 
duced symptoms of intoxication. After a short period of intoxication, 
with increased action of the heart and accelerated respiration, the animals 
became somnolent; respirations deep, slow, and irregular, assisted by the 
action of all accessory muscles of respiration; pupils dilated, temperature 
normal, diarrhoea, fasces bloody; speedy death. At the necropsy the 
heart was found contracted, the blood was of a dark color, and ecchymosis 
of the pericardium and peritoneum existed. There were no microorgan- 



674 PRINCIPLES OF SURGERY. 

isms in the blood. The pathological conditions described here are an 
accurate duplication of the post-mortem description in fatal cases of an- 
thrax. The same author succeeded subsequently in isolating, by a com- 
plicated process, a toxic substance from the bodies of anthracic rabbits 
with the formula C 3 H 6 N" 2 , which he called anthracin, besides a small quan- 
tity of methyl-guanidin. To the former substance he attributes the toxic 
symptoms in cases of anthrax. Injected subcutaneously in rabbits, it pro- 
duced first restlessness, rapid pulse, and accelerated respiration, followed 
by somnolence, deeper and slower respiration, diarrhoea, asphyctic symp- 
toms, convulsions, and death. This substance is closely allied to kreatin, 
and contains 23 per cent, of nitrogen. These experiments leave but little 
doubt that the fatal termination in cases of anthrax is caused by the action 
of toxic substances formed in the body in consequence of the action of the 
bacilli upon certain as yet unknown combinations in the organism. 



DIFFERENTIAL DIAGNOSIS. 

Anthrax must be distinguished from other forms of acute circum- 
scribed inflammation, notably from furuncle and carbuncle. A furuncle 
is conical from the beginning, and the summit is transformed into a small 
slough. A carbuncle is nothing more nor less than a multiple furuncle, 
and is produced by the same microbic cause. Anthrax develops from a 
single centre, and the infiltration proceeds from this point in all direc- 
tions. Necrosis is preceded by vesication, and the black, necrosed tissue 
is fully exposed after exfoliation of the epidermis. The ©edematous form 
of anthrax might be mistaken for erysipelas or acute phlegmonous inflam- 
mation. Anthrax oedema is usually not attended by much discoloration 
of the skin, and there is no such distinct and abrupt line of limitation 
as in erysipelas. Phlegmonous inflammation, when advanced to the ex- 
tent where it may resemble anthrax oedema, has gone on to the stage of 
suppuration. The differential diagnosis between malignant oedema and 
anthrax can only be made by searching for the primary microbic cause by the 
use of the microscope. A positive differential diagnosis between suppurative 
lesions and anthrax can be made in the course of one or two days by 
inoculation experiments. If a rabbit or mouse is infected with a drop of 
anthracic blood or serum taken from the centre of the inflammatory 
product, death from anthrax will follow within two days; while the same 
amount of fluid taken from a suppurative depot will produce no effect, or, 
at most, only a circumscribed abscess. As the anthrax bacillus can be 
readily stained and identified under the microscope, a positive differential 
diagnosis between these affections can always be made by the use of the 
microscope. 



TUKATMENT. 675 



PROGNOSIS. 



The Location of the disease, the character of the tissues primarily 
affected, and the general condition of the patient greatly influence the 
prognosis in cases of anthrax. The prognosis is most favorable in young, 
healthy individuals suffering from anthracic pustule, as in such instances 
the general strength of the patient and the active tissue proliferation at 
the seat of infection are well calculated to prevent general infection; 
while, in persons debilitated from any cause affected with the cedematous 
variety, general infection is very liable to follow. An anthrax oedema of 
the hand or arm is a less serious condition than a similar affection of the 
face or neck. As a general rule, it may be stated that, the firmer and 
more circumscribed the local lesion, the more favorable the prognosis, and 
vice versa, the more extensive the area of infection and the more diffuse 
the oedema, the greater the danger to life from general infection. The 
occurrence of general infection may be recognized without difficulty by 
the general symptoms, which indicate the existence of progressive septic 
infection. The bacillus of anthrax multiplies with great rapidity after 
its entrance into the circulation, and the anthracin, which produces the 
septic symptoms, is elaborated in amounts proportionate to the number 
of bacilli in the body. Fever, cough, rapid respiration, feeble and rapid 
pulse, diarrhoea, and delirium are some of the symptoms indicating that 
the disease has become general. All hope of recovery must be abandoned 
as soon as general infection has occurred; death from progressive infec- 
tion and intoxication will be certain to take place, in spite of the most 
heroic local and general treatment. 

TREATMENT. 

The surgical treatment of anthrax must be directed toward the 
elimination or neutralization of the primary microbic cause. As within 
the living body the reproduction of the primary cause takes place ex- 
clusively by segmentation of the bacilli, any germicidal agents that in- 
hibit or destroy the pathogenic property of the bacilli will be found useful 
in the local treatment of anthrax. It has been found experimentally that 
a 5-per-cent. solution of carbolic acid will arrest the growth of anthrax 
cultures, and clinical experience has demonstrated that the same solution, 
when brought in contact with the infected tissues by parenchymatous in- 
jections, has a decided influence in arresting further extension of the 
infection. 

Lande reports 2 cases of malignant anthrax saved by parenchymatous 
injections of carbolic acid. In the first case, a man aged 27, the upper 
lip was the seat of the disease; in the second, a woman aged 65, the 



676 PEINCIPLES OF SURGEEY. 

anthrax occupied the region below the scapula. Both patients were very 
ill, low delirium and other symptoms of toxaemia being present. The 
injections were made into the subcutaneous tissue around the pustule. 
The strongest solution used consisted of 15 grammes of neutral glycerin 
and an equal part of distilled water, in which 3 grammes of pure carbolic 
acid were dissolved. The injections were made at five points around the 
pustule, and represented a total dose of 50 centigrammes of the acid. The 
injections caused considerable pain, but very rapid improvement followed. 
The solution used (10 per cent.) was stronger than any previously employed 
for the same purpose by Boeckel, Eaimbert, and others. A 5-per-cent. 
solution in ordinary cases is strong enough, but in grave cases the 10-per- 
cent, solution must be used until improvement takes place, which should 
occur within forty-eight hours. Potiejenko has tried the parenchymatous 
injections of a 10-per-cent. solution of carbolic acid in four exceedingly 
severe cases of anthrax, and has obtained a complete cure in all of them. 
Three or four syringefuls of the solution were injected into the swelling 
and its neighborhood once daily, the part being kept covered in the inter- 
val with compresses soaked in a 5-per-cent. solution of the same antiseptic. 
Amoldow speaks very highly of the treatment of anthrax by parenchyma- 
tous injections of corrosive sublimate dissolved in a 5-per-cent. solution of 
carbolic acid in the proportion of 2 grains to the ounce. The object of the 
parenchymatous injections should be to saturate, as far as possible, all of the 
infected tissues with the antiseptic for the purpose of destroying the bacilli, 
and, at the same time, to permeate the surrounding healthy tissue for some 
distance, with a view of destroying the soil for the growth of the microbes 
in advance of the invasion. The surface over the entire infected area 
should be rendered thoroughly aseptic, in order to prevent secondary in- 
iection with pus-microbes through the needle-punctures. The punctures 
should be made a few lines from the border of infiltration, but always 
toward the centre of the infected district. The injection is made gradu- 
ally as the needle is withdrawn, so as to saturate the tissues for some 
distance along the entire length of the track of the needle. At one sitting 
from four to twelve injections are made, according to the size of the 
anthrax and the urgency of the symptoms. A compress wrung out of a 
l-to-1000 solution of corrosive sublimate should be kept constantly ap- 
plied. Application of an ice-bag over the antiseptic compress will assist 
the germicidal agents in retarding or arresting further multiplication 
of the bacilli in the tissues. The injections should be repeated every six 
hours until the disease is under control, or until it is deemed unsafe, from 
the quantity injected, to administer more carbolic acid for fear of causing 
intoxication. Excision has been objected to on the ground that the wound 
might become a new source of infection, and thus leave the patient in a 



n;i: \TMKvr. 677 

more precarious condition, so far as general infection is concerned, than 
before the operation, but such is not the case if the area of infection is 
limited and the incisions ran be made through healthy tissue. The fol- 
lowing case affords a ^^uh] illustration of the value of excision of anthrax 
in well-selected cases: — 

KalotV, of St. Petersburg, in making experiments with anthrax on 
animals, accidently infected himself, either by a needle-puncture or by 
handling the organs of anthraeie animals. The local infection appeared 
on the outer side of the thumb of the left hand as a small vesicle, which 
soon disappeared, but gave place to circumscribed infiltration on the sec- 
ond day. This inflammation rapidly extended, and was surrounded by 
hemorrhagic vesicles. The indurated tissues were promptly removed by 
excision; nevertheless, on the next day. swelling of axillary glands on the 
same side, fever, great prostration, also diarrhoea, set in. The skin in 
the axillary region and side of chest was much swollen and, at different 
points, bright red, at others bluish red. One of the axillary glands, the 
size of a hen's egg, and glands along the margins. of the pectoralis major 
muscle were removed and the field of operation thoroughly disinfected with 
a 5-per-cent. solution of carbolic acid; the same solution was also thrown 
into the surrounding tissues with an hypodermic syringe. Cessation of 
fever and rapid healing of wound, followed by recovery. The diagnosis 
was confirmed by successful cultivations made with fragments of the ex- 
cised tissue in bouillon and gelatin. Excision should always be resorted 
to in cases of anthrax pustule, as it fulfills the etiological indications more 
promptly and thoroughly than any other treatment. The incisions should 
be made outside of the indurated tissues, and, for the purpose of pre- 
venting traumatic dissemination of the disease, the surface, after thorough 
irrigation, should be brushed over with a 10-per-cent. solution of carbolic 
acid before the wound is sutured. This procedure will destroy any bacilli 
that may have become deposited upon the surface of the wound. 

In the case just cited it is possible that lymphatic infection — an un- 
usual occurrence in anthrax — developed in consequence of the entrance 
of bacilli into the open lymphatic vessels on the surface of the wound. 
Miiller asserts that it is impossible to eliminate the disease by excision of 

seat of inoculation. In guinea-pigs amputation of the limb performed 
a few hours after the foot had been inoculated failed to save the animal. 
He recommends the following treatment: Immobilize the affected part 
and neighboring joints to prevent dissemination. Elevate the limb. 
Apply mercurial ointment and give alcohol in large doses. On the other 
hand, Tillmanns insists that anthrax remains local longer in man than in 
animals, and that, consequently, more is to he expected from excision and 
cauterization. He recommends early excision, cautery, and parenchyma- 



678 PRINCIPLES OF SURGERY. 

tous injections around the area of infection of a l-to-1000 solution of 
mercuric bichloride or a 5-per-cent. solution of phenol. Lengzel and 
Koranyi saved 13 out of 142 cases by efficient local treatment. Free and 
early excision and parenchymatous injections of a 5-per-cent. solution of 
carbolic acid constitute the local treatment which the average surgeon 
would almost instinctively resort to in cases of accessible anthracic in- 
fection. Excision under strict aseptic precautions is also justifiable in 
anthrax oedema, even if all of the infected tissues cannot be removed, as 
sterilization of the remaining portion of the infected tissues can be secured 
subsequently more efficiently by parenchymatous injections than if the 
primary focus of infection is allowed to remain as a hot-bed for pro- 
gressive infection. In such cases it would be good practice to sear the 
whole surface of the wound with the actual cautery, for the purpose of 
preventing general and regional dissemination by the entrance of bacilli 
into the open lumina of veins and lymphatics, and also to increase the re- 
sisting capacity of the tissues to infection by exciting an active tissue- 
proliferation. The actual cautery would prove successful in recent cases, 
in cutting short an attack, if resorted to before any considerable infiltra- 
tion has occurred. It is said that shepherds, in districts where anthrax 
is endemic, destroy the vesicle with a red-hot needle as soon as it is de- 
tected, and it is seldom that the infection does not yield to this treat- 
ment. At this early stage the whole area of infection is limited, and 
could be most effectually destroyed with the sharp point of a Paquelin 
cautery. The general symptoms in severe cases of local anthrax, and after 
general infection has occurred, resemble the clinical aspects of septicaemia 
produced by other causes, and patients suffering from general primary or 
secondary anthrax require the same stimulating, tonic, and supporting 
treatment that has been laid down in the treatment of septicaemia. 



CHAPTER XXVII. 



Glandees. 



Synonyms. — Farcy; equinia; malleus humidus; Morve; Kotzkrank- 
heit. A contagious disease characterized by multiple foci of inflammation 
and suppuration, and caused by infection with a specific microbe: the 
bacillus mallei. The disease originates in the horse, and occurs in men 
by contagion. Although glanders in man is a rare affection, it presents, 
from a bacteriological study, so many points of interest that it merits 
more than a passing notice. It is one of the infectious diseases whose 
mierobic cause is now thoroughly understood. 

BACTERIOLOGICAL HISTORY OF THE DISEASE. 

That glanders in man occurred as an infection from the horse species 
of animals has been known for a long time. Its contagiousness among 
horses was asserted by Solleysel in the seventeenth century. Bindfleisch 
believed that he saw vibriones in the granular contents of glanderous 
abscesses. Klebs detected, in cultures of pus taken from animals suffer- 
ing from this disease, small rods and granules, but cultivations and inocu- 
lations in rabbits failed. The presence of minute organisms in cases of 
glanders was pointed out by Christatt and Kiener in 1868, and their obser- 
vations were corroborated by Bouchard, Capitan, and Charrin, who found 
the organisms not only in parts exposed to the air, such as nasal ulcera- 
tions and pulmonary abscesses, but also in parts not so exposed, such as 
the spleen, liver, and lymphatic glands. Chaveau demonstrated by his 
experiments that the virus of glanders was fixed to small, solid particles, 
as he found the sediment, which formed after diluting pus with water, 
active. This discovery marked an advance in the knowledge of the phys- 
ical nature of the virus. Loffler and Schtitz are the discoverers of the 
bacillus of glanders in horses. In 1882 they made a preliminary report 
of their researches (Deutsche med. Wochenschrift, 1882, No. 52). In 1886 
Lofner published his elaborate monograph on this subject ("Die iEtiologie 
der Kotzkrankheit," Arbeiten aus dem Kaiserlichen Gesundheitsamte zu 
Berlin, Bd. i, pp. 141-199). About the same time 0. Israel made cultures 
upon blood-serum from nodules of three glanderous horses, with which he 
produced the disease artificially in rabbits. The bacilli contained in these 
cultures correspond with the description of those isolated by Schiitz and 
Loftier. Soon after Loffier's first paper appeared, Bouchard, Capitan, and 
Charrin published almost simultaneously the results of their researches 

(679) 



680 PRINCIPLES OF SURGERY. 

and observations; but it appears from Loffler's second paper that none 
of them had been able to produce a pure culture. Kitt and Weichsel- 
baum were the first who, by their own investigations, were able to cor- 
roborate the correctness of Loffler's discovery: the former by his observa- 
tions and experiments on animals, the latter by a case of glanders in the 
human subject that came under his own observation. 

DESCRIPTION OF BACILLUS MALLEI. 

According to Loffler, the bacillus of glanders appears as a small rod, 
which is somewhat shorter and broader than the tubercle bacillus; its 
length varies but little, and corresponds to about two-thirds of the di- 
ameter of a red blood-corpuscle; the thickness varies between one-fifth 
and one-eighth of its length. It is a non-motile, aerobic microbe. 

These bacilli are either straight or slightly curved and rounded at 
their ends. Usually, they are found in pairs in a parallel direction, held 
together by a delicate, unstained pellicle. Examined in a drop of fluid, 
they show active molecular movements. Spontaneous movements could 

Fig. 227.— Bacilli of Glanders from a Young Potato Culture. X 950. (Baumgarten.) 

not be observed by Loffler. The colorless and sometimes even somewhat 
dilated portions of the stained bacillus are not spores, but, as Loffler 
affirms, indications of commencing death. Loffler found that bacilli kept 
in a dry state for three months could occasionally be made to grow, but 
in most instances, after a few weeks, they could no longer be cultivated, 
which fact speaks against the existence of spores. On the other hand, 
in favor of the presence of endospores must be regarded the results ob- 
tained by Eosenthal, in Baumgarten's laboratory, with Neisser's method 
of staining spores, who showed that at least some of the- bacilli contain 
spores, while in others the points which refuse staining material are un- 
doubtedly, as Loffler claims, evidences of vacuolar degeneration. 

(a) Staining. — The method of staining the bacilli of glanders is 
characteristic; when the bacilli are treated by basic and aniline dyes no 
effect is produced. 

Method of Schiitz. — The sections are placed for twenty-four hours 
in the following mixture: Potash solution (1 in 10,000), concentrated 
alcohol, methylene-.blue solution: equal parts. Wash the sections in a 
watch-glass with water acidulated with 4 drops of acetic acid. Transfer 



TENACITY OF BACILLUS MALLEI. 681 

for five minutes to 50-per-cent. alcohol, clarify in clove-oil, and mount in 
Canada balsam. 

Loffler's Method. — Sections are immersed for a few minutes in a 
solution of potash (1 in 10,000), then for a few minutes in an alkaline 
solution of methyl-blue; after which they are decolorized with a solution 
of tropa?olin in acetic acid, or, what is still better, in a fluid composed of 
10 centimetres of distilled water, 2 drops of sulphuric acid, and 1 drop of 
a 5-per-cent. solution of oxalic acid. 

(b) Cultivation. — When cultivated on solid sterilized blood-serum at 
a temperature of 38° C. (100.4° F.), the growth appears in the form of 
minute transparent drops on the surface, which consist exclusively of the 
characteristic bacilli. Cultures upon boiled potato — according to Lofner, 
Kitt, and TTeichselbaum — form in three days a uniform amber-yellow 
layer, that about the sixth to the eighth day assumes a reddish hue, resem- 
bling the color of oxide of copper, which is not easily mistaken for any 
other culture upon the same soil. Upon this nutrient medium the bacilli 
were cultivated through twelve generations, and the cultures retained 
their activity for a year; whether the bacillus w r as capable of cultivation 
after this time is not mentioned. The temperature at which cultures could 
be made to grow varied from 30° to 40° C. (86° to 104° F.). The bacillus 
also grows in neutralized bouillon, with and without the addition of pep- 
tone. The culture first renders the fluid turbid, and, later, settles on the 
bottom of the vessel as a w T hite, shining mass. Weichseibaum succeeded 
in growing the bacillus upon ordinary nutrient agar and gelatin. Easkina 
rendered these nutrient media more fertile for the growth of this microbe 
by the addition of chicken-matron albuminate. Kranzfeld succeeded best 
with Xocard and Eoux's mixture: meat-peptone, glycerin-agar-agar. 

TENACITY OF BACILLUS AIALLEI. 

Lofner ascertained that this bacillus shows the same degree of re- 
sistance to heat and germicidal substances as other bacilli without spores. 
The bacillus is destroyed by exposure for ten minutes to a temperature of 
55° C. (131° F.). It is also destroyed by a 3- to 5-per-cent. solution of 
carbolic acid in five minutes, and in two minutes in a l-to-5000 solution of 
corrosive sublimate. Bonome has drawn the following conclusions from 
his studies concerning the life-history of the bacillus of glanders: 1. The 
bacillus is present in all glanderous inflammatory products and in the 
urine and milk of the diseased animals. 2. It can pass from mother to 
foetus through a healthy placenta. 3. It is very susceptible to the de- 
structive influences of desiccation. It loses its virulence when kept in a 
dry state at a temperature between 25° and 30° C. in the absence of other 



682 PRINCIPLES OF SURGERY. 

organic matter, and ceases to grow if the drying process is continued for 
more than ten days. 4. If the drying process is imperfect, as is the case 
in an old agar culture, the virulence is retained for several weeks. In dis- 
tilled water the bacillus dies in from five to six days. 5. It offers a rela- 
tively great resistance to heat. 6. Cadaverin in the proportion of 1 to 
40,000 or 1 to 60,000 causes the bacilli to grow in long filaments and de- 
prives them of their pathogenic properties. 7. The bacillus does not grow 
in the serum of a glanderous horse. 8. In normal ox-serum the bacillus 
presents almost the same phenomena; this serum, filtered after the pro- 
longed contact with the bacilli, possesses curative properties against the 
disease in certain animals. 9. The serum of dogs collected during the 
treatment with mallein is an unfavorable medium for the growth of the 
organism. This may explain the protective influence against the disease 
in this animal. 

INOCULATION" EXPERIMENTS. 

Kitt enumerates the following animals as being susceptible of inocu- 
lation with the virus of glanders: Tiger, lion, cat, sheep, goats, guinea- 
pigs, horse, ass, rabbits, and white rat. Pigs, dogs, the common rat, ducks, 
and chickens possess great immmunity; the inoculations at best produce 
only a slight local reaction. Lofner made his first experiments on guinea- 
pigs and the field-mouse. In the guinea-pigs he observed, three to five 
days after subcutaneous injection of a pure culture, an ulcer at the point 
of inoculation, and at the end of the first week swelling of the nearest 
lymphatic glands, attended by suppuration. At this stage of the disease 
the process often came to a stand-still and the animals recovered. In 
many animals the disease progressed quite rapidly to a fatal termination. 
Abscesses were frequently found in the testicle and the epididymis in the 
male, and in the breast and external genital organs of the female. The 
face, nasal cavity, and ankle-joint were also frequently the seat of ulcera- 
tive processes. In case the disease proved fatal, death usually occurred 
three or four weeks after inoculation. At the post-mortem, aside of the 
affections enumerated, nodules were found in the spleen, lungs, and fre- 
quently in the liver. The histological structure of a recent nodule bears 
a great resemblance to tubercle. The bacilli are always found more 
numerous in the nodules if the disease is produced artificially by inocula- 
tion. The inflammatory product is first composed almost exclusively of 
epithelioid cells, between which leucocytes from the periphery insinuate 
themselves. Giant cells are never found in glanderous nodules; the epi- 
thelioid cells are derivatives of connective tissue and endothelial cells; 
while the leucocytes escape from the inflamed capillary vessels. Baum- 
garten constantly observed karyokinetic figures in the epithelioid cells. 



[NOCULATION EXPERIMENTS. 683 

The leucocytes that cuter the nodule soon show evidences of frag- 
mentation, and are converted into pus-corpuscles. The bacilli are dis- 
tributed among the cellular elements singly, in pairs, and in groups. Some 
of them may be seen also within the cellular elements, especially the 
epithelioid cells. 

Field-mice proved a great deal more susceptible to the virus of glan- 
ders than guinea-pigs, as they usually died three or four days after in- 
oculation. The necropsy in these animals showed, at the point of inocu- 



A U9 lb &®* 







(.«. •* » « v,-»' ^-j-- - - -.-.': • -yorM'ir *.-■■' r- *■■ v« y ^. .v -. live/ v . w .* «5Stf»3 ( o >•;; ~--_ 



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Fig. 228. — Glanderous Nodule from the Liver of a Field-mouse. (Bismarck-brown 
staining. Bacilli stained after Lomer's method. Bacilli magnified and drawn twice 
this size.) K, karyokinetic figures in epithelioid cells. X 250. (Bamngarten.) 

lation, an infiltration from which swollen lymphatic vessels led to the 
nearest lymphatic glands. In the spleen and liver, which were always 
found greatly enlarged, numerous small nodules could be seen, while the 
remaining internal organs presented a normal appearance. Glanders in 
guinea-pigs and field-mice presents a series of pathological changes that 
cannot be mistaken for any other affection. The bacilli of glanders in 
the different organs can be detected most readily in recent specimens. 
In the blood bacilli were detected only in very acute cases: a circum- 



684 PRINCIPLES OF SURGERY. 

stance that explains why so many inoculations with the blood of glander- 
ous horses proved unsuccessful. The bacilli of glanders are evidently 
strictly tissue-, and not blood-, parasites. 

Lundgren took a nodule from the lungs of a horse that had died of 
glanders, and implanted fragments of it under the skin of rabbits. The 
animals died about the nineteenth day after inoculation, and the necropsy 
revealed induration and small abscesses at the point of infection, and 
small, yellow nodules in the spleen, liver, lungs, testicles, and mucous 
membrane of the nose. Implantation of spleen-tissue into other rabbits 
fixed the period of incubation in this animal at from eleven to twelve days. 

Kranzfeld has published the results he obtained by inoculations with 
the virus of glanders in an animal hitherto not subjected to experimenta- 
tion of this kind. He procured a pure culture from a nodule of a man who 
had died of glanders after a brief illness. Inoculations were made in a 
small rodent which is very numerous in the southern part of Eussia, the 
Spermopliilus guttatus. The course of the disease in this animal was al- 
most the same as in the field-mice that were used by Loffier. Of 28 ani- 
mals infected with different cultures, 16 died on the fourth day, 9 on the 
fifth, 2 on the seventh, and 1 on the tenth. The post-mortem appearances 
were always characteristic: a greenish-gray infiltration at the point of 
inoculation and a number of nodules in the spleen; in one animal also very 
small, white nodules in the liver. Cultivations from these nodules yielded 
a pure growth of the bacillus of glanders. If animals are infected by 
direct injection of a pure culture into a vein, no serious symptoms are 
produced; but, if soon thereafter one or more muscles are injured sub- 
cutaneously, the microbes escape through the lacerated vessels, localize at 
the seat of injury, and produce a grave form of the disease. It has been 
determined by experiment that the farther from the trunk the inocula- 
tions are made, the less intense is the local reaction. When an animal is 
inoculated at a distance from the trunk, and shows no general symptoms, 
a subcutaneous injury of any portion of the trunk will furnish the neces- 
sary conditions for the development of a local form of infection. 

It had been generally believed that the intact skin furnished an 
adequate protection against infection with the bacillus of glanders until 
the experiments of Babes and Nocard proved that infection can take place 
through the healthy skin. Nocard rubbed a pure culture of the bacillus into 
the skin in two guinea-pigs, and found on the fifteenth day some of the 
hair-follicles the seat of glanderous inflammation. Histological examination 
showed numerous bacilli in the follicles, the epithelial layer much thickened, 
and the surrounding connective tissue in a state of proliferation. The infec- 
tion had extended from the follicles through the connective tissue into the 
lymphatic vessels underneath, as was evident from the presence of bacilli in 



GLANDERS IN THE EORSE. G85 

the Lymphatic glands, vessels, and connective-tissue spaces in the immediate 

vicinity of the primary lesion of the skin. 

GLANDERS IN THE HORSE. 

Glanders and farcy in the horse are different manifestations of the 
same disease, and, as each of them is divided into an acute and chronic 
form, we tind described four varieties of the disease in this animal: acute 
and chronic glanders, acute and chronic farcy. 

Acute Glanders. — This form of glanders is attended by a high tem- 
perature (106° to 109° F.) and other symptoms of acute sepsis, and proves 
uniformly fatal in a few days. The breathing is accelerated, the pulse 
feeble and rapid, and there is complete loss of appetite. The nasal mu- 
cous membrane, at first of a dark, coppery color, with dark-red ecchymotic 
patches, becomes purple; these ecchymoses are rapidly converted into 
ulcers, from which issues a copious sero-sanguinolent discharge. Lym- 
phatic infection is a characteristic feature of acute glanders. The sub- 
maxillary and cervical glands enlarge and suppurate, discharging unhealthy- 
looking, ichorous pus. Abscesses also form in the lymphatics of the face. 

Chronic Glanders. — This is the form most commonly seen in the horse. 
The disease begins in the mucous membrane of the nose. Small, whitish 
nodules, composed of small, round cells, are formed in the mucous mem- 
brane. These nodules soften and ulcerate. Similar nodules may be found 
in the larynx, trachea, and bronchi. The ulcerations may remain super- 
ficial, or they may extend to the deep tissues, even attacking cartilage 
and bone. The internal organs, especially the lungs, may become the 
seat of metastatic foci. The left nostril appears to be affected more fre- 
quently than the right. The lymphatic glands underneath the lower jaw en- 
large very rapidly, often reaching considerable dimensions during a single 
night. The glandular swellings may continue for several days, afterward 
slowly disappear, and then reappear as rapidly as before. The discharge 
from the nostrils presents a starchy or glue-like appearance, adheres to 
the mucous membrane, where it dries and accumulates, causing narrowing 
of the nasal opening. 

Acute Farcy. — Acute farcy, together with chronic farcy, is simply an- 
other manifestation of glanders, and is initiated in a very similar manner 
to acute glanders. There are the same lesions of the lymphatics and 
nodules, and abscesses are found in the skin. A general swelling of the 
cutaneous tissues takes place, varying in size for a time, but suddenly a 
number of distinct swellings or nodules will appear, termed "farcy-buds/' 
These specific nodules, so characteristic of farcy in either its acute or 
chronic form, involve the skin, subcutaneous connective tissue, or they 
may extend to the deeper tissues. They vary in size from a pea to a 



686 PRINCIPLES OP SURGERY. 

hazel-nut. These nodules suppurate, and, after evacuation of their con- 
tents leave ragged ulcers that discharge a foul, grayish- white, creamy 
liquid tinged with blood. When several ulcers are in close proximity 
they may become confluent and form an extensive ulcerating surface. 
"With the appearance of the nodules the lymphatics become inflamed, 
swollen, and indurated. Xot infrequently acute farcy terminates in the 
development of acute glanders, with all the pathological conditions that 
have been described as characteristic of that disease, thus showing their 
etiological identity. 

Chronic Farcy. — In this form of glanders the lymphatic glands are 
principally involved. The disease is not attended by much febrile dis- 
turbance, and all of the other general symptoms are less marked than in 
the other varieties of glanders. The lymphatic glands become enlarged, 
and nodules are formed in the skin, lungs, and other viscera. Central 
softening and suppuration of the nodules is a regular occurrence. Long, 
fistulous tracts often result from extensive undermining of the skin. In 
all of these different forms of glanders in the horse the cause remains the 
same, and the pathological conditions are identical; only the clinical as- 
pects vary from the location, intensity, and extent of the primary infection. 

GLANDERS IN MAN. 

In man the disease occurs in an acute and chronic form, but does not 
exactly resemble any of the varieties of the disease in the horse or the 
disease artificially produced in animals by inoculation. The discharge 
from the nostrils of a diseased horse, brought in contact with an abraded 
surface or a mucous membrane, will communicate the disease. Xocard 
made experiments to determine whether the bacillus of glanders could 
enter the intact skin. He rubbed a pure culture of the microbe into the 
sikn of 3 asses and 15 guinea-pigs. Of the 18 animals only 2 guinea-pigs 
were infected, and it is probable that, in these, infection occurred through 
minute excoriations of the skin. ^Notwithstanding the positive results that 
followed the cutaneous inoculations in guinea-pigs with a pure culture 
of the bacilli of glanders by Xocard, it is, for all practical purposes, safe 
to make the assertion that the virus of glanders can only find entrance 
into the organism through a wounded surface. "Whether infection may 
not take place through the alimentary canal has, so far, not been definitely 
ascertained. It is certain that the disease cannot be contracted by eating 
boiled or fried flesh of animals. Infection through the respiratory organs 
is possible, as cases have been reported in which the lungs were the pri- 
mary and only seat of the disease. The fact that man can be infected 
with a pure culture of the bacilli of glanders as successfully as the animals 



SYMPTOMS AND DIAGNOSIS. 687 

that have been successfully experimented on received a sad illustration 
a number of years ago in Vienna. 

Dr. Hoffmann, a young and promising physician, who was making 
some experimental investigations on animals with pure cultures, accident- 
ally inoculated himself with the needle used for making the inoculations, 
and died from acute glanders in a few days. Observations of veterinary 
surgeons and experimental researches have shown conclusively that the 
disease can be transmitted from the mother to the foetus in utero by pas- 
sage of the bacilli through the placenta from the maternal into the foetal 
circulation. When man is the subject of glanders, bacilli are found more 
constantly in the blood than in glanderous animals. In the case described 
by Weichselbaum, numerous bacilli could be seen in the blood. In this 
case a thrombus was found in one of the large meningeal veins, contain- 
ing numerous bacilli, and which, undoubtedly, was one of the sources of 
the bacilli in the circulation. In man the nasal mucous membrane is not 
so frequently affected as in animals, although Bollinger has shown that 
in horses the nasal cavity is not always affected, and that it may present 
a normal condition, even when the larynx and lungs are seriously affected. 
Muscular abscesses, that may simulate rheumatism, are of very frequent oc- 
currence, especially in the chronic form of the disease. 

SYMPTOMS AND DIAGNOSIS. 

The symptomatology of glanders is variable, as it is greatly modified 
by the intensity of the infection, the primary location of the disease, and 
the number and distribution of the metastatic foci. The disease may 
begin at a single point, and may then be mistaken for a carbuncle or a 
gangrenous erysipelas. Graefe reports a case which began as an acute 
exophthalmos, and the nature of the disease was not ascertained until 
after death. In this case there were nodules in the choroid of the eye. 
Acute glanders runs a rapid and malignant course. Infection usually 
takes place through a small wound, puncture, or abrasion about the face 
or hands. At the point of inoculation a somewhat elongated, soft, in- 
flammatory swelling or nodule forms in a few days. Central softening 
and suppuration soon transform the inflammatory product into an under- 
mined ulcer, with irregular, ragged margins, surrounded by a wall of 
infiltration. In mild cases the disease may remain local, and the ulcer 
heals under proper treatment in a few weeks. In other cases regional in- 
fection takes place, and the lymphatic glands become swollen and sup- 
purate, leaving the same kind of ulcers as at the primary seat of infection. 

In the fatal cases general infection takes place either through the 
veins or the lymphatic vessels, and the symptoms then resemble septi- 
caemia or pyaemia, or a combination of these two diseases: septopyaemia. 



688 PRINCIPLES OF SURGERY. 

Errich reports a case of glanders which was remarkable for the fact that 
the elbow-, knee-, and ankle- joints were the seat of pyaemic suppuration. 
Forestier describes a case in which numerous subcutaneous abscesses ap- 
peared which contained hemorrhagic pus. ,Brault and Eouget observed a 
case in which seventeen subcutaneous abscesses appeared and four large 
joints were the seat of suppurative inflammation. If infection take place 
directly through the veins, a thrombophlebitis develops in connection with 
one of the nodules and the bacilli in the thrombus, which multiply in this 
nutrient medium and gain entrance into the general circulation singly or 
through the medium of infected emboli. Under such circumstances, 
nodules are found in the lungs, kidneys, and other internal organs, as sup- 
purating metastatic deposits in muscles, bone, joints, and testicle. In such 
cases the general symptoms may simulate to perfection typhoid fever, 
pyaemia, suppurative osteomyelitis, and acute general miliary tuberculosis. 
In acute cases where general infection occurs early and rapidly, death re- 
sults in from one. to three or four weeks, while in chronic cases the final 
fatal termination is often postponed for months. In illustration of the 
clinical history of this disease I will quote briefly a few cases. 

A Eussian medical journal of recent date states that a young soldier, 
who had been a wagoner before his admission into the army, was received 
into the military hospital suffering from two foul ulcers on the hard 
palate, which had perforated the nasal fossa and destroyed the inferior 
turbinated bones. Three weeks later a swelling appeared over the eye- 
brow; a fortnight afterward he complained of pain on the inner side of 
the left knee, around the internal tuberosity of the tibia. A purulent 
discharge occurred from the left ear, and, at the same time, an abscess 
developed on the back of the right hand which appeared as a deep-purple 
tubercle, with a hard circumference, and sunken toward the centre; a 
purulent discharge oozed from the surface; at first, for a short time after 
admission, the temperature varied, rising in the evening to 103°-10-1° F.; 
later on it fell to normal. The disease was mistaken for syphilis, and 
iodide of potassium was given without the least benefit. About ten weeks 
after admission he was in better health, and left the hospital, receiving 
his discharge from the army. Within a few weeks he returned, with ex- 
tension of ulceration of the hard palate; the uvula was destroyed. The 
characteristic nodules, the "farcy-buds," appeared in the face; the meta- 
static abscess on the back of the hand remained. The patient ultimately 
died of exhaustion. Before death some of the nodules were extirpated; 
they were found to contain microorganisms resembling to perfection the 
bacillus of Lofner and Schiitz. 

Kiittner reports a number of cases in which the skin was the seat 
of numerous points of suppuration in the form of pustules, or more dif- 



SYMPTOMS AND DIAGNOSIS. 



689 



fuse abscesses followed by ulceration. The disease has been mistaken 
more frequently for syphilis than any other affection. This mistake in 
diagnosis is very liable to be made in the chronic form, in which the 
nodules grow very slowly, are hard, and may occur in groups or like a 
string of beads. The nodules usually soften and form chronic ulcers, 
which closely resemble the ulcers resulting from the breaking down of 
gummata. If the disease primarily attack the nasal cavity, the mucous 
membrane presents hard nodules, and a copious discharge from the nose 
is present. In acute glanders affecting the nose and face, extensive de- 
struction of tissue by the rapid breaking down of the nodules is one of 
the prominent clinical features of the disease. Complete destruction of 
the nose, with formation of large ulcers of the face, may happen in the 
course of a week. 

Chronic glanders may also be easily mistaken for tuberculosis of the 




Fig. 229. — Acute Glanders, Involving Nose and Pace, showing Extent of Local Lesions 
Eight Days after the Commencement of the First Symptoms. (Birch-Hirschfeld.) 



skin, mucous membranes, and lymphatic glands. Buschke describes a case 
of chronic glanders localized in one extremity, this being the fifth recorded 
case. Acute glanders may simulate furuncle, carbuncle, and other sup- 
purative lesions, as well as lymphangitis and erysipelas. In making a 
differential diagnosis between these different affections and glanders, it is 
important, if possible, to trace the infection to its proper source. If the 
clinical history point to the possibility of infection by contact with a 
glanderous horse, it should be remembered that the period of incubation 
in man varies from two days to three weeks. A positive diagnosis must 
necessarily rest on the detection of the specific microbe in the granulation- 
tissue or in the discharges, and the results obtained by inoculation ex- 
periments. The method of inoculation as an aid in diagnosis, proposed by 
Strauss, is of great value. This consists in the injection of cultures or of 



690 PRINCIPLES OP SURGERY. 

the suspected crude products into the peritoneal cavity of a male guinea- 
pig. If the disease is glanders, a positive diagnosis can be made within 
three or four days. At the end of this time the scrotum is red and glossy, 
the cuticle desquamates, and suppuration occurs. The bacillus of glanders 
can be found in the pus. The animal usually dies in the course of twelve 
to fifteen days. When the animal is killed three or four days after the 
inoculation suppuration of the testicle and its envelopes can be demon- 
strated and the bacillus of glanders is invariably present in the products 
of, the suppurative inflammation. As soon as general infection has taken 
place, the symptoms resemble pyaemia or septicaemia; so that a differen- 
tial diagnosis between metastatic glanders and general infection with pus- 
microbes cannot be made without the aid of the microscope and inocula- 
tion experiments. 

PATHOLOGY AND MORBID ANATOMY. 

The bacillus of glanders resembles, in its immediate action on the 
tissues, both the bacillus of tuberculosis and the pus-microbes. The 




' -<w^|^- •'•■-•-~c I. 

Fig. 230.— Section of a Glanders Nodule. X 700. (Fliigge.) 

histological change first observed in the infected tissues is a transforma- 
tion of mature into embryonal tissue, the microscopical picture, with the 
exception of the absence of giant cells, resembling tubercle; but this stage 
is of short duration, as the pyogenic effect of the bacillus of glanders soon 
produces purulent softening by the speedy conversion of the embryonal 
cells and leucocytes into pus-corpuscles. The formation of abscesses is 
a constant occurrence, wherever localization has taken place, either by 
direct infection, secondary infection from regional diffusion through the 
lymphatic vessels and connective-tissue spaces, or by general infection 
by embolic diffusion through the general circulation. 

As soon as the disease has become general, the clinical picture and 
pathological conditions are the same as in pyaemia caused by a suppu- 



TREATMENT. 691 

rative Lesion. The differentiation between the two forms of metastasis 
can be made only by demonstrating the primary cause, by use of the 

microscope or by the results obtained from inoculation experiments-. The 
pus found in glanders is grayish red in color, and quite tenacious in recent 
lesions, but after opening the abscesses it assumes the character of ordi- 
nary pus, as the abscess-cavities then become the seat of secondary in- 
fection with pus-microbes. Swelling and abscesses of the testicles have 
been frequently observed in cases where the disease has become general, 
the affection in these organs being one of the clinical manifestations that 
embolic dissemination has occurred. Primary glanders of the lungs from 
inhalation of the microbes into the air-passages gives rise to symptoms 
and pathological conditions that cannot be distinguished from pulmonary 
tuberculosis, unless the essential cause can be demonstrated in the sputa 
under the microscope, or glanders can be artificially produced by the in- 
jection of sputum into the subcutaneous tissue or the peritoneal cavity 
of guinea-pigs. The pulmonary nodules soften and suppurate, and cavities 
form in the same manner as in pulmonary tuberculosis. 

PROGNOSIS. 

The prognosis in glanders should always be guarded, as a limited 
local lesion may be followed by a fatal form of general infection. The 
prognosis is comparatively favorable if the infection remain limited to 
a circumscribed area accessible to direct surgical treatment. It must be 
more guarded if regional infection through the lymphatic vessels has 
occurred, and it is absolutely fatal in cases of primary glanders of im- 
portant internal organs, and when general infection has followed in the 
course of a local lesion with or without regional dissemination. In the 
local form of the disease the ulcerations usually prove inveterate to treat- 
ment, and the final recovery is often retarded for months by extensive 
undermining of the skin. Acute glanders with general infection, as a rule, 
proves fatal within one to three weeks, and death occurs in consequence 
of septic infection. 

TREATMENT. 

The prophylactic treatment consists in preventing infection from 
glanderous horses and substances which have become contaminated with 
the specific virus from diseased animals, and requires 'early recognition 
of the disease and killing of the affected animals, as well as thorough 
disinfection of the premises occupied by the diseased beast. The ca- 
davers should be cremated or deeply buried. Abrasions or granulating sur- 
faces that have been exposed to infection should be cauterized. 

In cases of primary pulmonary or intestinal glanders, and after gen- 



692 PRINCIPLES OF SURGERY. 

eral infection from a local form of the disease has occurred, the treatment 
must be necessarily symptomatic, as such cases are beyond the reach of 
local or general treatment. The embarrassed respiration and feeble and 
rapid pulse indicate the use of alcoholic stimulants. A primary nodule 
should be removed by excision, taking all necessary precautions to pre- 
vent infection of the wound in case the skin has been destroyed by ulcera- 
tion. Limited regional infection should be treated in the same manner 
if ulceration has not taken place, and the conditions are such that all of 
the infected tissues can be removed with safety. 

Gold reports two cases of glanders in man cured by mercurial in- 
unctions. In one of these cases sixty-two inunctions were made. He 
states that he has observed about thirty cases of glanders, and that, with 
the exception of the two treated by this method, all proved fatal. All 
subcutaneous abscesses were duly opened and washed out with a l-to-500 
solution of corrosive sublimate. All ulcers were similarly disinfected with 
the lotion, then painted with nitric acid and dressed antiseptically. The 
total quantity of mercurial ointment rubbed into the patient in the course of 
sixty-five days amounted to 1 pound, 1 ounce, and 3 drachms. The treat- 
ment with mallein does not appear to have yielded the expected results, as 
J. Bates reports four cases treated by this antitoxin with negative results. 

After multiple abscesses have formed a radical operation is no longer 
indicated, the extent of the affection precluding the possibility of removing 
all of the infected tissues. In such cases the abscesses should be freely 
incised, fistulous tracts laid open, undermined skin cut away, and, as far 
as possible, the infected tissues removed with a sharp spoon; then the 
entire surface should be disinfected with a 12-per-cent. solution of chlo- 
ride of zinc. No attempt should be made, under such circumstances, to 
obtain healing of the superficial wounds until it becomes apparent that 
the specific microbic cause has been eliminated or destroyed, and several 
repetitions of the curetting and disinfection may become necessary until 
this object is realized. The scraped surfaces should be kept covered with 
a moist antiseptic gauze compress, wrung out of l-to-2000 solution of 
corrosive sublimate or a 2-per-cent. solution of carbolic acid. If the pro- 
longed use of these antiseptics is objectionable on account of danger from 
absorption of toxic doses of these drugs, strong iodine-water can be used 
in the same way. The internal use of iodine, creasote, and arsenic has 
been recommended as specifics in the treatment of glanders, but clinical 
experience has not supported this claim, and the surgeon must rely upon 
local measures in his efforts to protect the patient against the dangers 
arising from regional and general infection; while he must aim, at the 
same time, to maintain the resisting power of the tissues to the microbic 
invasion by a supporting tonic and stimulating treatment. 



1XPKX. 



Abnormal and defective callus. .".7 
Abscess, 248 
acute, 250 

diagnosis, 251 

treatment, 253 
chronic, 254 

diagnosis, 255 

treatment, 255 
iliac, 512 
lumbar, 512 
of brain, 323 

cerebral localization, 325 

prognosis, 324 

symptoms and diagnosis, 323 

treatment, 322 
of internal organs, 309 
of lung, diagnosis, 338 

exploration, 339 

operation, 340 
psoas, 512 
tubercular, 509 

pathological anatomy, 509 

prognosis, 513 

symptoms and diagnosis, 511 

treatment, 513 
Absolute asepsis, 23 
Accurate suturing, 26 
Achromatin, 8 
Actinomycosis hominis, 619 
clinical varieties, 628 
description of fungus, 620 
history, 619 
of brain, 638 

of bronchial tubes and lungs, 626 
pathology and morbid anatomy, 626 
prognosis, 642 
sources of infection, 625 
symptoms and diagnosis, 639 
treatment, 451 
Action of bacteria on tissues of body, 165 
Acute glanders, 685 
suppuration, 244 
tetanus, 451 
Amputation in tuberculosis of joints, 589 
Anthrax, 659 

attenuation of virus, 666 

clinical varieties, 668 

description of bacillus, 660 

differential diagnosis, 674 

history, 659 

in living body and in soil, 662 

infection in man, 664 

inoculation experiments, 662 

intensification of virus, 666 

multiplication, 662 

cedema, 670 

of external surface, 669 

pathology and morbid anatomy, 671 



Anthrax, prognosis, 675 

prophylactic inoculations, 66o 

pustule, 669 

treatment, 675 
Antiphlogistic treatment of inflammation, 149 
Arterial blood-supply, defective, 194 
Arteries, ligation of, 194 
Arthrectomy, in tuberculosis of joints, 582 
Arthritis, suppurative, 309 
Ascites, tubercular, 544 
Asepsis, 23 

Aspiration in tuberculosis of joints, 581 
Atrophy, 81 

Attenuation of pathogenic bacteria, 167 
Atypical resection, 585 

Bacilli of putrefaction, 366 
Bacillus coli communis, 238 

of anthrax, description of, 660 

multiplication of, 662 
mallei, 679 
description of, 680 
tenacity of, 681 
pyocyaneus, 235 
pyogenes fcetidus, 366 
tetani, 437 

toxins of, 444 
tuberculosis, 477 
cultivation, 482 
description, 479 
manner of infection and dissemination, 

529 
staining, 479 
Bacteria, 157 

action of, on tissues of body, 165 
attenuation, 167 
classification, 157 
cultivation, 162 
death-point, 161 
elimination, 181 
fission, 159 
growth, 164 
immunity, 170 

inoculation experiments, 167 
localization, 173 
multiplication, 159 
outside of the body, 170 
presence of, in healthy body, 171 
putrefactive, 192 

secondary, or mixed, infection, 178 
specific, 189 
spores, 160 

therapeutic inoculation, 169 
transmission of, from parents to foetus, 182 
Bacteriological causes of suppuration, 220 
Bladder, tuberculosis of, 612 

prognosis and treatment, 614 
symptoms and diagnosis, 613 



(693) 



694 



INDEX. 



Blastomycetic dermatitis, 645 
diagnosis, 656 
fungus of, 648 

inoculation experiments, 651 
pathological anatomy and histology, 653 
prognosis, 658 
treatment, 658 
Blood-corpuscles, red, 96 

white, 94 
Blood-plates, 97 

Blood-vessels, regeneration of, 42 
Blue pus, 243 
Bone ferrule, 63 

regeneration of, 54 
splint, 63 
suture, 63 
tuberculosis, 550 
artificial, 551 
clinical and bacteriological researches, 

552 
means of differential diagnosis, 562 
pathology and morbid anatomy, 554 
prognosis, 564 

symptoms and diagnosis, 560 
treatment, 565 
Brain abscess, 323 

actinomycosis of, 638 
exploration of, 330 
Bronchial tubes and lungs, actinomycosis of, 
626 

Callus, 54 

Capillary vessels, 93 
Cancer aquaticus, 210 
Carbuncle, 265 

diagnosis, 266 

treatment, 267 
Cartilage, 33, 133 
Catarrhal inflammation, 128 
Caustics producing necrosis, 197 
Cauterization of wound in hydrophobia, 470 
Cell-division, 13 

Central nervous system, regeneration of, 67 
Chemical pyogenic substances, 223 
Chromatin, 8 

five phases of, 9 
Chronic circumscribed suppurative osteomye- 
litis, 305 
pathological anatomy, 307 
symptoms, 306 
treatment, 307 

glanders, 685 

inflammation, 140 

suppuration, 245 

tetanus, 452 
Cicatrization, 19 
Classification of bacteria, 157 
Clinical forms of erysipelas, 425 

septicaemia, 363 

suppuration, 244 

surgical tuberculosis, 506 
Cloudy swelling, 83 
Coagulation-necrosis, 205 



Cold producing necrosis, 196 

Color in gangrene, 201 

Condition of tissue in necrosis, 201 

Connective tissue, regeneration of, 42 

Cornea, inflammation of, 130 

regeneration of, 31 
Corpuscle, third, 96 
Croupous inflammation, 129 
Cultivation of bacteria, 162 

Decubitus, 194 

Defective arterial blood-supply, 194 

Degeneration, 81 

amyloid, 88 

colloid, 86 

fatty, 84 

mucoid, 86 

waxy, 86 
Dermatitis, blastomycetic, 645 
Diabetic gangrene, 210 
Diapedesis, 115, 210 
Diphtheritic inflammation, 130 
Direct causes of suppuration, 222 

transmission of bacteria, 182 

union of wounds, 3 
Disturbance of function in inflammation, 118 
Division of cells, 13 
Dry gangrene, 208 

Elimination of gangrenous part, 203 

pathogenic bacteria, 181 
Elongation of tendon, 53 
Embolism, 395 

Emigration of leucocytes, 95 
Emphysema in gangrenous tissue, 200, 207 
Empyema, 332 

after-treatment, 337 
multiple resection of ribs, 337 
thoracoplastic operation, 338 
bacteriological studies, 332 
diagnosis, 333 
prognosis, 334 
treatment, 334 
drainage, 336 

evacuation of pus and removal of mem- 
branes, 336 
incisions, 335 
irrigation, 336 
resection of rib, 335 
Encapsulation of necrosed tissue, 203 
Endocranial suppuration, 315 
Epidermization, 22 

Epididymis and testicle, tuberculosis of, 608 
symptoms and diagnosis, 610 
treatment, 610 
Epiphyseolysis, 282 
Epithelia, 36 
Epithelioid cells, 497 
Ergot as a cause of gangrene, 197 
Ergotin as a cause of gangrene, 214 
Erysipelas, 411 
bullosum, 426 
clinical forms, 425 



iM)i:\. 



695 



Erysipelas, description of streptococcus ery- 
sipelatosus, 413 

erythematosuin, 426 

facialis, 42S 

gangrenosum, 427 

history of microbic origin, 411 

inoculation experiments, 414 
for therapeutic purposes, 415 

manner of infection, 416 

metastaticum, 427 

migrans, 428 

phlegmonous, 426 

prognosis, 429 

relation of, to puerperal fever, 419 
phlegmonous inflammation and suppura- 
tion, 420 

symptoms, and diagnosis, 423 

traumatic, 429 

treatment, 430 
Erysipeloid, 433 

Essential condition for growth of bacteria, 164 
Excision of wound in hydrophobia, 469 
Experiments, inoculation, of bacteria, 167 
Exploration of brain, 330 

lung, 330 
External parts, gangrene of, 198 
Exudation, inflammatory, 110 

Fallopian tubes, tuberculosis of, 605 

symptoms and diagnosis, 607 

treatment, 607 
False joints, causes of, 59 
Farcy, acute, 685 

chronic, 685 
Fascia tuberculosis, 597 
Fermentation fever, 363 

symptoms and diagnosis, 364 
Fibrous tubercle, 501 
Fission of bacteria, 159 
Fistula, 273 
Fixed tissue-cells, 98 
Folliculitis, suppurative, 264 
Foot, perforating ulcer of, 214 
Fragmentation of nucleus, 12 
Furuncle, 264 

Gangrene caused by ergot, 197 

color in, 201 

diabetic, 210 

dry, 208 

elimination, 203 

hospital, 212 

line of demarcation, 202 

moist, 208 

of external parts, 198 

prognosis, 214 

progressive, 207 

senile, 208 

swelling, 200 

symmetrical, 197 

treatment, 215 
Gangrenous tissue, emphysema in, 200 
Genito-urinary organs, tuberculosis of, 604 



Giant cells, 495 
Glanders, 679 

acute, 685 

bacteriological history, 679 

chronic, 685 

in man, 6s6 

in the horse, 685 

inoculation experiments, 682 

pathology and morbid anatomy, 690 

prognosis, 691 

symptoms and diagnosis, 687 

treatment, 691 
Glands, 65 

kidney, 65 

liver, 65 

lymphatic, 66 

spleen, 65 

testicle, 65 
Glans penis and urethra, tuberculosis of, 6 
Gonococcus, 237 
Granulating surfaces, skin-grafting in, 38 

wounds, suturing of, 29 
Granulation-tissue, 13 

vascularization of, 16 
Granulomata, 141 
Growth of bacteria, 164 

Hsemorrhagic inflammation, 122 

Haemostasis, 25 

Head tetanus, 452 

Healing of wounds, 2 

Heat as a cause of necrosis, 196 

symptom of inflammation, 118 
Histogenesis of suppuration, 220 

tubercle, 492 
Histological structure of tubercle, 490 
Histology of tubercle, 490 
Histozym, 364 
Hospital gangrene, 212 
Hyaline tubercle, 502 
Hydrophobia, 459 • 

a microbic disease, 461 

causes, 463 

in the dog, 460 

pathology and morbid anatomy, 467 

prognosis, 466 

symptoms and diagnosis, 464 

treatment, 469 
cauterization of wound, 470 
excision of wound, 469 
palliative, 474 
prophylactic, 469 
inoculations, 470 

Icterus, hsematogenous, 401 

Immediate, or direct, union of wounds, 3 

Immunity, 139 

Incubation period of tetanus, 446 

Indirect causes of suppuration, 222 

Infection-atrium of bacillus tetani, 447 

Inflammation, 91 

catarrhal, 128 

chronic, 140 



696 



INDEX. 



Inflammation, croupous, 129 
diphtheritic, 130 
emigration of leucocytes, 111 
hemorrhagic, 122 
histological elements in, 92 
interstitial, 122 
modification of, 120 
of mucous membranes, 127 
of non-vascular tissue, 130 
of serous membranes, 123 
parenchymatous, 120 
phlegmonous, 420 
prognosis, 144 
suppurative, 123, 128 
symptoms, 100 

symptoms and diagnosis, 143 
treatment, 146 

anodynes, 155 

antiphlogistic, 149 

antipyretics, 153 

antiseptic fomentations, 152 

application of cold, 151 

counter-irritation, 155 

diet, 154 

elevation of inflamed parts, 150 

ignipuncture, 156 

massage, 155 

parenchymatous injections, 147 

physiological rest, 150 

stimulants, 154 

tonics and alteratives, 154 
Inflammatory exudation, 110 

transudation, 117 
Inoculation experiments of bacteria, 167 

tuberculosis in man, 485 
Inoculations, prophylactic, 456 
Internal necrosis, 197 

organs, abscess of, 309 
Intestinal sepsis, 382 
Iris, tuberculosis of, 519 

Joints, tuberculosis of, 569 
etiology, 570 

pathology and morbid anatomy, 571 
prognosis, 578 

symptoms and diagnosis, 574 
treatment, 579 

amputation, 589 

arthrectomy, 582 

aspiration, 581 

atypical resection, 585 

rest, 580 

tapping and iodoformization, 581 

typical resection, 588 
varieties of, 572 

Karyokinesis, 8 
Karyolysis, 198 
Karyomytosis, 8 
Karyorhexis, 198, 206 

Large cavities, suppuration in, 309 
Leptomeningitis, suppurative, 319 



Leucocyte, 94, 495 

emigration oi, 95 
Ligation of arteries in their continuity causing 

gangrene, 194 
Liquefaction of necrosed tissues, 203 
Localization of bacteria, 173 
Loss of function in osteomyelitis, 283 
Lung abscess, 338 
Lupus, tubercular nature of, 338 
Lymphatic glands, tuberculosis of, 529 

pathological histology and morbid anat- 
omy, 531 

prognosis, 536 

symptoms and diagnosis, 533 

treatment, 536 
Lyssa nervosa falsa, 466 

Macrocytes, 495 

Malignant oedema, 360 

Mammary gland, tuberculosis of, 603 

Mastzellen, 56 

Metastatic suppuration, 401 

Microbe en chapelet, 384 

Microbic cause of tetanus, 447 

origin of erysipelas, 411 
suppuration, 220 
tuberculosis, 475 
Micrococcus gonorrhoeae, 237 

pyogenes tenuis, 232 
Modification of inflammation, 120 
Moist gangrene, 208 
Mouth and tongue, tuberculosis of, 598 

pathology, 598 

symptoms and diagnosis, 599 

treatment, 600 
Mucous membrane, inflammation of, 127 

suppurative inflammation of, 247 

transplantation of, 41 
Mummification, 202 
Muscles, regeneration of, 47 
non-striated, 47 
striated, 48 

suture of, 50 

tuberculosis of, 596 
Myeloplaques, 57, 496 

Necrobiosis, 207 

Necrosed tissue, liquefaction of, 203 

Necrosis, 187 

coagulation, 205 

encapsulation, 203 

etiology, 187 

general symptoms, 203 

internal, 197 

pathological and clinical varieties, 205 

prognosis, 214 

symptoms, 198 

treatment, 215 
Nerves, peripheral, regeneration of, 69 
Nerve-suture, 74 

primary, 75 

secondary, 76 
Nervous system, central, regeneration of, 67 



INDEX. 



697 



Noma, 210 

Non-vascular tissue, inflammation of, 130 
regeneration of, 31 

cartilage, 33 

cornea, 31 
Nucleus, fragmentation of, 12 

Obstructed venous circulation, 195 
Odor of necrosed tissue, 202 
CEdema, malignant, 360 
Opening of the skull, 329 
Operation, thoracoplasty, 33S 
Origin of suppuration, 220 
Osseous tuberculosis, cause of, 550 
Osteoclasts, 57 
Osteomyelitis, suppurative, 274 

early operations, 295 

intermediate operations, 296 

late operations, 297 

Pachymeningitis, suppurative, 315 
Pain a symptom of inflammation, 100 

necrosis, 19S 

osteomyelitis, 200 
Parenchymatous inflammation, 120 
Paronychia, 262 
Perforating ulcer of foot, 214 

stomach and duodenum, 213 
Pericarditis, suppurative, 340 
Pericardium, incision and drainage, 341 

puncture and aspiration, 341 
Peritoneum, tuberculosis of, 541 

bacteriological remarks, 541 

clinical studies, 542 

pathology and morbid anatomy, 543 

symptoms and diagnosis, 545 

treatment, 546 
Peritonitis, adhesive, 545 

fibrinoplastic, 544 

suppurative, 342 
Phagocytosis, 134 
Phlegmonous erysipelas, 426 

inflammation with suppuration, 256 
Physiological rest, 27, 150 
Plasma-cells, 99 

-rhexis, 207 
Platycytosis, 134 
Progressive gangrene, 207 

with emphysema, 207 
Prophylactic inoculations, in hydrophobia, 470 
Proteus mirabilis, 367 

vulgaris, 367 

Zenkeri, 368 
Ptomaines, 165, 368 

Puerperal fever, relation of erysipelas to, 419 
Pulse, after ligation of artery, 199 
Purulent infiltration, progressive, 259 
Pus, 240 

blue, 243 

-corpuscles, 240 

description and specific action of microbes 
of, 230 

red, 243 



Pus-serum, 240 

Putrefactive bacteria, 192, 366 

Pyaemia, 383 

bacteriological and experimental re- 
searches, 384 

etiology, 388 

in rabbits, 385 

pathological anatomy, 404 

prognosis, 404 

symptoms and diagnosis, 400 

treatment, 406 
Pyogenic microbes as a cause of sepsis, 362 

substances, chemical, 223 

Ray-fungus, 620 

Raynaud's disease, 197 

Red pus, 243 

Redness a symptom of inflammation, 101 

osteomyelitis, 281 
Regeneration, 1 

of different tissues, 31 
Rest, physiological, 27 
Reticulum, tubercle, 498 
Rib, resection of, in empyema, 335 
Ribs, multiple resection of, 337 

Sapraemia, 365 

prognosis, 373 

symptoms and diagnosis, 372 

treatment, 374 
Senile gangrene, 208 
Senkungsabscess, 512 
Sepsis, intestinal, 382 

pyogenic microbes as a cause of, 362 
Septicaemia, 354 

bacteriological researches, 354 

clinical forms, 363 

in mice, 354 

in rabbits, 357 

progressive, 375 
causes, 376 

pathology and morbid anatomy, 380 
prognosis, 379 

symptoms and diagnosis, 377 
treatment, 380 
Septopysemia, 409 

kryptogenetic, 409 

spontaneous, 409 
Serous membranes, inflammation of, 123 
Skin, tuberculosis of, 520 

pathology and morbid anatomy, 523 

prognosis, 526 

symptoms and diagnosis, 524 

treatment, 527 
Skin-grafting, 38 
Skin-transplantation, 38 

Hirschberg's method, 41 

Reverdin's method, 38 

Wolfe's method, 411 
Skull, opening of, 329 
Specific bacteria, 189 
Spores of bacteria, 160 
Staphylococcus cereus albus, 231 



698 



INDEX. 



Staphylococcus cereus flavus, 232 
epidermidis albus, 232 
flavescens. : .\. 
pyogenes albus, 231 

citreus, 2oi 
Stomach and duodenum, perforating ulcer of, 

213 
Strahlenpilz, 61a 
Streptococcus erysipelatous, 413 

pyogenes, 234 
Suppuration. .. 
acute, 244 

bacterial causes and histogenesis of, 220 
chronic, :.45 
clinical forms, 244 
direct causes, 222 
endocranial, 315 

history of microbic origin of, 220 
in large cavities, 309 
in wounds, 246 
indirect causes, 222 
metastatic, 401 
relation of erysipelas to, 420 
subacute, 245 
Suppurative arthritis, 309 

bacteriological researches, 309 

symptoms and diagnosis, 312 

treatment, 313 
inflammation, 13 \ 

of mucous membrane, 247 
leptomeningitis, 319 

symptoms and diagnosis, 321 

treatment, 322 
osteomyelitis, 274 

bacteriological and experimental investi- 
gations, 275 

causes. ITS 

chronic circumscribed, 305 

diagnosis, 283 

history of, 274 

pathological anatomy. L ; ~ 

prognosis, 285 

symptoms, 279 

treatment, 290 
pachymeningitis, 315 

symptoms and diagnosis, 316 

treatment, 317 
pericarditis, 340 
peritonitis, 342 

bacteriological and experimental re- 
searches, 342 

causes, 346 

clinical and bacteriological studies, 345 

symptoms and diagnosis, 349 

treatment, 350 
tendo-vaginitis, 261 
Surface epithelia, 36 
Surgical tuberculosis, 475 

clinical forms, 506 
Suture of bone, 63 
muscles, 50 
nerves, 74 
tendons, 51 



Suturing, 26 

of granulating wounds, 29 
Swelling a symptom of inflammation, 109 

osteomyelitis, 2S1 
Symmetrical gangrene, 197 
Symptoms of inflammation, 100, 143 
Synovitis, 2S1, 572 

Temperature in gangrene, 199 

Tenderness a symptom of osteomyelitis, 200 

necrosis, 199 
Tendon-sheaths, tuberculosis of, 591 

pathology, 591 

prognosis, 593 

symptoms and diagnosis, 593 

treatment, 593 
Tendoplasty, 52 
Tenorrhaphy, 51 
Tetanus, 436 

acute, 451 

antitoxin, 455 

bacillus, 437 

bacteriological studies, 436 

chronic, 45:. 

clinical forms, 451 

cultivation, 437 

etiology, 446 

hydrophobicus, 452 

infection-atrium, 447 

inoculation experiments, 439 

neonatorum, 452 

pathology and morbid anatomy, 453 

period of incubation, 446 

prognosis, 452 

specific microbic cause, 449 

symptoms and diagnosis, 449 

toxins of the bacillus, 444 

treatment, 454 
Therapeutic inoculation of bacteria, 169 
Third corpuscle, 96 
Thoracoplasty operation, 338 
Thrombosis, 390 



necrosis. 



201 



Tissue, condition of, 

connective, 42 

granulation, 13 

non-vascular, 31 

vascular, 35 
Tissue-cells, fixed, 98 
Tissues, action of bacteria on, 165 

regeneration of, 1 
Toxins and ptomaines, 165 

of bacillus tetani, 444 
Transmission of bacteria, 1S2 
Transplantation of mucous membrane, 41 

skin, 38 
Transudation, inflammatory, 117 
Trauma, 193 

Traumatic erysipelas, 429 
Treatment of acute abscess, 253 

anthrax, 675 

brain abscess, 325 

carbuncle, 267 

chronic abscess, 255 



1 N 1) K X . 



G99 



Treatment of empyema, 334 
erysipelas, 430 
furuncle, 265 
gangrene, 215 
glanders, 691 
hydrophobia, 469 
inflammation, 146 
necrosis, 215 
paronychia, 263 

phlegmonous inflammation, 257 
purulent infiltration, 260 
pyaemia, 406 
saprsemia, 374 
septicaemia, 380 
suppurating wounds, 28 
suppurative arthritis, 313 

leptomeningitis, 322 

osteomyelitis, 290 

pachymeningitis, 317 

peritonitis, 350 

tendo-vaginitis, 261 
tetanus, 454 
tubercular abscess, 513 

tendo-vaginitis, 593 
tuberculosis of bladder, 615 

bone, 565 

epididymis and testicle, 610 

Fallopian tubes, 607 

joints, 579 

lymphatic glands, 536 

mammary gland, 603 

mouth and tongue, 600 

peritoneum, 546 

skin, 527 

tendon-sheaths, 593 

vulva, vagina, and uterus, 605 
wounds, 23 

skin-grafting in 38 
Trismus, 452 
Tubercle, fibrous, 501 
hyaline, 502 

nodule, arrangement of cells in, 4 
growth of, 500 
reticulated, 501 
reticulum, 498 
Tubercular abscess, 509 
ascites, 544 
tendo-vaginitis, 591 

pathology, 591 

prognosis, 593 

symptoms and diagnosis of, 593 

treatment, 593 
Tuberculosis of bladder, 612 
bones, 550 

epididymis and testicle, 608 
Fallopian tubes, 605 
fascia, 597 

genito-urinary organs, 604 
glans penis and urethra, 608 
joints, 569 
intestine, 601 



Tuberculosis of kidney, 617 
lymphatic glands, 529 
mammary gland, 603 
mouth and tongue, 598 
muscles, 596 
peritoneum, 541 
tendon-sheaths, 590 
the iris, 519 

skin, 520 

stomach, 601 

vascular system, 618 

vesiculse seminales, 611 

vulva, vagina, and uterus, 604 
Tuberculosis, surgical, 475 
calcification, 505 
caseation, 502 
description of bacillus, 479 
growth of tubercle-nodules, 500 
hereditary and acquired disposition, 506 
histogenesis of tubercle, 492 
histological structure of tubercle, 494 
histology of tubercle, 490 
history of microbic origin, 475 
inoculation experiments, 482 

in man, 485 
pathological varieties, 501 

Ulcer, 269 

diagnosis, 271 

of foot, 214 

of stomach and duodenum, 213 

treatment, 272 
Ulceration and fistula, 269 
Union of wounds by primary intention, 6, 23 

by secondary intention, 27 

immediate or direct, 3 



Varieties of tuberculosis of joints, 572 
Vascular tissue, regeneration of, 35 

surface epithelia, 36 
Vascularization of granulation-tissue, 16 
Venous circulation, obstructed, 195 
Vesiculae seminales, tuberculosis of, 611 
Vessels, capillary, 93 
Vulva, vagina, and uterus, tuberculosis of, 604 

"Wound, cauterization of, in hydrophobia, 470 
excision of, 469 
healing of, 2 

immediate or direct union of, 3 
of blood-vessels, regeneration of, 42 
skin-grafting in, 38 
suppuration in, 246 
suturing of granulating, 29 
treatment of, 23 

absolute asepsis in, 23, 28 
treatment of suppurating, 28 
union by primary intention, 6, 23 

secondary intention, 27 



